Please initial the following:

AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Initial*   I authorize the release of any medical information to specialty providers and offices necessary to further my treatment through referrals. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered valid as an original. I understand that holistic treatments are not a substitute for medical diagnosis and treatment, and no medical claims are made regarding these treatments.

FINANCIAL AGREEMENT
Initial*   All FWIM account balances are due at the time of service. Deposits are required to schedule any and all appointments - $75 for new patient appointments, $75 for all follow up appointments and procedures. Medication refills and focused email correspondence will incur a $50 charge for services rendered. Email correspondence is subject to no more than 2 exchanges per focused topic or request. More in depth requests may require an appointment with a provider.

CONSENT TO CARE
Initial*   I request and give consent to Dr. Veerula, the nurse practitioners, their associates and assistants who may provide me medical care to perform such medical-surgical care, tests, procedures, and other necessary services as well as provide drugs and supplies as they consider necessary or beneficial for my health and well-being. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to me or relied upon on me. In addition, I understand there may be adverse effects or complications from some treatments/procedures/drugs, etc.

NO SHOW/CANCELLATION POLICY:
When you make an appointment, we are reserving time in our clinician's schedule that is no longer available to other patients. If you are unable to make it to an appointment, FWIM requires that you cancel (or re-schedule) your appointment at least 72hrs prior to your scheduled appointment time. Deposits can be transferred for timely rescheduled appointments up to two times. If you cancel or reschedule within 72hrs or are considered a no-show, your deposit is forfeited as a no-show/cancellation fee. Breach of this policy on three or more than three consecutive occasions can be grounds for discharge from the clinic. Note that the cancellation fee may be waived in special circumstances, determined on an individual basis (eg: medical emergency, patients may be asked to provide documentation for the same).

PRE-APPOINTMENT CHECK IN POLICY:
Telemedicine or Telephone Appointments:
Our staff will attempt to call you 2 times and email you starting 30-60 minutes prior to your scheduled appointment. This call is necessary to review medications, the purpose of the appointment, review of symptoms, and confirm that your video link works. If we cannot contact you and do not hear back from you prior to your scheduled appointment time, your appointment will be cancelled and you will be considered a no show.
In-Person Appointments:
Patients must arrive 30 min prior to an in-person appointment in order to complete the check-in. Late arrival will shorten your appointment time.
Supplements and Medications:
It is the patient's responsibility to provide accurate and an up-to-date medication and supplement list prior to each appointment. This is a requirement for each appointment.
It is recommended all forms be completed online if possible. All forms are to be completed and submitted 72 hours prior to appointment.

1.  Initial* All office visits, telemedicine or consultations that have been completed and the patient has been seen by a provider are non-refundable.
2. Initial*   Email visits are $50.00 and are intended for brief questions regarding the patient's current treatment plan. Email visits are subject to no more than 2 exchanges each by patient and provider, and for established patients only. More than 2 exchanges will require an office or telemedicine visit. Email visits are only available to established patients.
3. Initial*   Provider appointments which are 30 min will consist of 20 min in clinical time and 10 min of charting time. Appointments that are 60 min in length will be 50 min of clinical time and 10 min of charting time.
4. Initial*   Office visits can be scheduled as in-office or telemedicine, based on patient request.
5. Initial*   After each appointment, the patient will receive an individualized treatment plan for reference.
6. Initial*   Patients must be available 30 min before their telemedicine or in-person appointment for the Medical Assistant to review the patient's medical history (triage). The Medical Assistant will contact the patient with 2 telephone calls and 1 email to confirm the appointment and to ensure the video conference link is properly working. If the patient is unavailable, they will forfeit their deposit and need to reschedule their appointment.
7. Initial*   Prescription refills are issued to both compounding and retail pharmacies. Patients must allow 48 hrs. (2 business days) for retail refills and 72 hrs. (3 business days) for compounding refills to process within our office. After this timeframe, patients are required to contact their pharmacy before pickup to confirm the refill has been completed.
8. Initial*   All provider communication is available only during regular business hours via email or phone. Correspondence is intended for brief questions regarding your plan. Any detailed questions will require an office visit.
9. Initial*   An existing patient is defined as visiting the office within a 2-year (24 mos.) timeframe. Anything outside of 2-years (24 mos.) will be considered a new patient and requires an initial office visit with any provider at the listed rate.
10. Initial*   Deposit of $75 must be made at the time of scheduling. Reimbursement for scheduled office visits is available if canceled before 72hrs. (3 business days) of appointment time. If cancelations or rescheduling occur after 72hrs. (3 business days) the patient will forfeit their deposit. Balance is due at time of appointment.
11. Initial*   Please refer to our BHRT information and pricing at FWIMED.com/providerfees. BHRT pellet therapy pricing may vary based on dosage. A Superbill will be provided per patient request for out-of-network insurance billing for office visits and BHRT pellet therapy.
12. Initial*   Bioidentical hormone pellets will require bloodwork for the first two pellet insertions. Once symptoms have stabilized bloodwork will only be required annually.
13. Initial*   Interest accrues at the rate of 1% per month for any amounts remaining unpaid for more than ninety (90) days following the date of the service. Additional charges for returned checks ($25.00 per check) will be invoiced to the patient and are due prior to the next appointment.
14. Initial   Fort Wayne IV Lounge and Ft. Wayne Integrative Medicine maintain a social media presence which can include photographs of patients, patient's families, and therapy sessions. Inclusion for the social media presence is strictly voluntary and is not endorsed or compensated. To enable Fort Wayne IV Lounge and Ft. Wayne Integrative Medicine to include a photo for our social media page or print materials, we require a signature. I waive any right to inspect and approve the finished copy or product. Fort Wayne IV Lounge and Ft. Wayne Integrative Medicine offers appointment and lab reminders by directly texting patients. Patient information will not be shared or published.