New Patient Intake

I (the patient or patient representative) am authorizing FFC SLEEP LLC to perform reasonable and necessary medical examinations, testing and treatment. I consent to treatment at this office and intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended.

I understand that I have the right to discuss any and all treatment with my physician about the purpose, potential risks and benefits of tests ordered for me.

I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice.

I (the patient or patient representative) make the following acknowledgments:

I acknowledge that as a courtesy, FFC SLEEP LLC may bill my insurance company for services provided to me and agree to pay for services that are not covered or covered charges not paid in full including, but not limited to any co-payment, co-insurance and/or deductible, or charges not covered by insurance. I understand that there is a fee for returned checks.

I acknowledge that FFC SLEEP LLC may utilize the services of a third party business
associate or affiliated entity as an extended business office (“EBO Servicer”) for medical account billing and servicing.

I hereby assign to FFC SLEEP LLC any insurance or other third-party benefits available for health care services provided to me. I understand FFC SLEEP LLC has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to FFC SLEEP LLC, I agree to forward all health insurance or third-party payments that I receive for services rendered to me immediately upon receipt.

I certify that any information I provide, if any, in applying for payment under Title XVIII (“Medicare”) or Title XIX (“Medicaid”) of the Social Security Act is correct. I request payment of authorized benefits to be made on my behalf to FFC SLEEP LLC by the Medicare or Medicaid program.

I agree that, in order for FFC SLEEP LLC, or Extended Business Office (EBO) Servicers and collection agents, to service my account or to collect any amounts I may owe, I expressly agree and consent that FFC SLEEP LLC or EBO Servicer and collection agents may contact me by telephone at any telephone number, without limitation of wireless, I have provided or FFC SLEEP LLC or EBO Servicer and collection agents have obtained or, at any phone number forwarded or transferred from that number, regarding the services rendered, or my related financial obligations.Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

In addition to traditional Internal Medicine and Sleep Medicine services, Fresh Fit Consulting offers an expanded group of services that fall under the category of “Restorative Medicine”. These offerings go above and beyond those traditionally available to patients under insurance coverage. Among other use cases, Restorative Medicine services provide valuable insight into metabolic function, hormone management, and medication alternatives.

We ask all FFC patients, regardless of participation status, to familiarize themselves with the following disclosures: 

• No financial commitment is associated with the completion of this form.
• Participation is 100% voluntary. Patients may freely choose not engage in any restorative medicine services and still be seen at Fresh Fit Consulting.
• Fees associated with Restorative Medicine services are ineligible for insurance submission. Payment is expected at the time of service. Appeals can not be made to insurance companies as no claims will be submitted.
• Despite extensive research and clinical data demonstrating effectiveness of these treatment strategies, Restorative Medicine Services often extend beyond the standard recommendations for care set by the American Board of Internal Medicine. Said Restorative treatment strategies are not the subject to FDA evaluation. The utilization of an alternative approach does not invalidate recommendations of traditional medical treatment plans and often serves as an adjuvant therapy.
• FFC utilizes a variety of dietary protocols, nutritional, and herbal supplements supporting the physiological and biomechanical processes of the human body. Although these foods and products may also be suggested with a specific therapeutic purpose in mind, their primary use is designed to support given aspects of metabolic function. Use of nutritional supplements may be safely recommended for patients already using pharmaceutical medications, but some potentially harmful interactions may occur. Fresh Fit Consulting can not anticipate and predict all risks and complications associated with such treatments. We ask patients to keep all of their healthcare providers fully informed about any and all medications, nutritional supplements, herbs, or hormones they may be taking. Patients voluntarily wish to rely on the administering physician to exercise judgment during the course of treatment based upon the facts then known.
• As a service to our patients, FFC makes nutritional supplements available in our office. We purchase only top quality products and only from manufacturers who have gained our confidence through considerable research and experience. Patients are under no obligation to purchase these products in our office, but we cannot guarantee a similar quality from an outside source.

Cancellation Policy
Patients who are unable to keep their scheduled appointments, are asked to notify the office within 24 hours of their appointment so that it can be scheduled for another patient in need.

Patients who fail to show for their scheduled appointments or do not notify the office within 24 hours of their scheduled appointment time, may be subject to a “No Show/Cancellation” fee of up to $75.00. Fees associated with the cancellation policy are not covered by insurance and are therefore the sole responsibility of the patient. In the event of an emergency where prior notice could not be given, consideration will be given solely at Dr Boesler’s discretion

Active Patients                                                                                                                             In order to receive patient courtesy services (medication refills, same day sick visits, or appointment referrals), patients must maintain an active status with the practice. Active status is defined as having completed a scheduled appointment in the last six months.

Combining Visit Types
Fresh Fit Consulting asks that our patients clearly communicate the discipline of medicine (internal medicine, sleep medicine, or restorative medicine) they are seeking treatment under prior to each appointment. Cross discipline concerns will need to be handled in independent appointments. Fresh Fit Consulting appreciates patient cooperation in limiting visit scope so we may provide focused, through, and efficient patient care.

Review of Ordered Testing
Testing ordered on behalf of the patient is ordered with the expectation that it will be discussed in person once results are received. The only exception to this rule is in the event that results are normal and do not require any clinical followup. Fresh Fit Consulting appreciates patient cooperation as we look to eliminate miscommunications that may arise when results are not discussed in person.

Phone Policy
Fresh Fit Consulting prioritizes serving patients with scheduled appointments who physically are present in the office. We can not promise to answer every phone call as it comes in. All patients are encouraged to leave detailed messages that will be returned in order of clinical urgency.  

Pre Authorization                                                                                                                           As per insurance policy, it is each patient's responsibility to understand their pre authorization requirements before any services are rendered. Fresh Fit Consulting can not guarantee prior authorization from patient insurance for procedures rendered. Patients will not be absolved of financial obligations based on unobtained or uncommunicated prior authorization requirements. Coverage information is available from each insurance provider on an individual basis.

Laboratory Testing Coverage  
As per insurance policy, it is each patient's responsibility to understand their laboratory testing coverage prior to the start of any testing. Fresh Fit Consulting can not guarantee insurance coverage for any laboratory testing ordered. Patients are responsible for confirming coverage prior to the rendering of any laboratory services. Fresh Fit Consulting is not in a position to negotiate service fees of third party providers on behalf of patients. In the event of a miscoded or illegible order, FFC will provide revised ICD codes directly to the patient or via fax to requesting third parties. Coverage information is available from each insurance provider on an individual basis.

FFC SLEEP LLC as a covered entity will create and recive Protected Health Information for each of our patients. PHI includes, but is not limited to:

• an individual's past, present, or future physical or mental health or condition
• the past, present, or future payment for the provision of healthcare to an individual
• identifiers of the individual with respect to which there is a reasonable basis to believe the information can be used to identify the individual 

 ■ 45 C.F.R. Sec. 160.103.

FFC SLEEP LLC as a covered entity receiving health information under this authorization will not receive direct or indirect remuneration in exchange for disclosing the health information for the purpose of marketing, the sale of the PHI or research.

By sigining below, I certify that I have read and fully understand the statements contained within: Consent to Treatment, Consent to Financial Communication, Restorative Medicine Disclosure, Practice Policies, and HIPAA Authorization, consenting fully and voluntarily to their contents.