Welcome to Dawson Integrative Medical Center, LLC. Our practice policies are outlined below and have been created to maintain the highest level of care for our patients.
APPOINTMENT SCHEDULING & PATIENT PROFILE (SAVED CREDIT CARD): We see patients by appointment only. While we try to accommodate emergency or same day appointments, please understand there might be a longer than normal wait time. All appointments are conveniently self-scheduled online using our Schedulicity portal. As a patient, you are required to keep an online profile and a credit card on file in this portal. The credit card is used to guarantee an appointment but is not charged at the time of scheduling (unless otherwise noted on that specific appointment type). Payments will be processed during the office visit check in process using the card on file. The saved card will also be used in the event of a late cancellation, no show, or any balance. You can also request for this card to be used for any additional products or services.
ARRIVAL TIMES: In an effort to provide excellent care to our patients, our schedule is kept on time and is strictly structured. This allows us to focus equal time and attention to each patient in a non-rushed manner. If you are a new patient, you must arrive 15 minutes early to process you as a new patient. If you have not completed new patient forms, you must arrive 20-30 minutes prior. If you arrive late or without the paperwork completed (and not have arrived 20-30 minutes prior), you will be rescheduled.
CANCELLATIONS & NO SHOWS: We require a 24 hour notice if you are unable to keep your appointment time. This allows us to provide that time to another patient in need. If you no show for an appointment or do not provide the required 24 hour notice, you will be charged a $100 fee to the card you have on file. If you have more than 2 late cancellation or no show occurrences, you may be subject to dismissal from the practice. We value your time and expect the same in return. We are a small practice that spends extended time with our patients. We often reserve 45-60 minutes for appointment times and when we are not given the courtesy of a 24 hour notice, we are unable to fill that time with another patient. This is the only way we are able to keep our fees so low and offer other cost effective services.
SCENT-FREE OFFICE: Please refrain from wearing fragrances to our office. We treat a number of patients that suffer from terrible allergic and autoimmune conditions that will exacerbate their symptoms when exposed.
BRINGING CHILDREN TO YOUR APPOINTMENT: While we are a family-friendly practice and see patients as young as 5 years old, we kindly request that parents only bring children to the office if the child is being seen. We spend an extended amount of time with our patients and many times, children do get restless and we have found that parents do not get the full benefit from their appointment with us. Additionally, there are very sensitive topics discussed during visits that are not appropriate for little ears. We respectfully request that you schedule your appointment when you have appropriate childcare OR schedule a telemedicine visit perhaps during nap time or a mutually convenient time for you and your child(ren).
MEDICATION POLICY: Please understand that our office practices within the Integrative Functional Medicine structure. This means our focus is on wellness, prevention, and reversal of chronic conditions, symptoms and disease. We DO NOT manage chronic medication management and we DO NOT prescribe or refill chronic medications, such as: blood pressure medications, cholesterol medications, anxiety/depression medications, etc. Since our goal is to help you reverse and manage these symptoms as naturally as possible, we work with you to make necessary steps to wean off medication. If you require medication management, we will refer you to the appropriate specialist. We DO prescribe on-going medication and refills for thyroid management, hormone management, weight loss and metabolic conditions. Additionally, we DO prescribe for short-term/acute issues, such as: illness, infection, pain, headaches, GI issues, etc. Medications are only filled during office visits.
AFTER HOURS CONTACT: If you find yourself in the unfortunate situation of an urgent medical need that is outside of our normal office hours, we ask that you text us at our contact number. If your need is medically urgent and you need to speak with a provider on call, there is a $20 after hours fee that will be charged to your credit card on file. If your need is not urgent, you will be responded to the next business day. If it is life-threatening or an emergency, we ask that you call 911 or go to the nearest emergency room and then inform us.
TREATMENT OF MINORS: We will see patients 5 years of age and older. Patients under the age of 18 must be accompanied by a parent or legal guardian. Please note that our office does not administer vaccinations. If vaccinations are requested or required, we will refer to the appropriate facility. School & Sports Physical Forms are completed at no extra charge if completed during an office visit.
LAB WORK: As a convenience to you, we do have the ability to draw labs in our office; however, there are certain tests that do require special processing, so you will be referred to the lab at that point. We do charge a nominal $20 lab draw fee. All specimens are then sent to the lab of your choice for processing. We do not handle any type of lab billing, so we encourage you to inquire with your insurance company to be sure the lab you have chosen is in your network and coverage/cost options. This is your responsibility.
REFERRALS/ORDERS: It might be necessary at times to refer you to a specialist, another provider, or a facility for services. Our office will provide you with the referral or orders. It is your responsibility to select a provider (unless we have made recommendations). You will need to inquire with your insurance company to ensure that the provider or facility is in your network and what the costs are.
DISMISSAL: If you are dismissed from the practice, it means you can no longer schedule an appointment or consider us your provider. Common reasons for dismissal include: failure to keep appointments, no show, or late cancel, non compliance with treatment plans, abuse to the staff, and failure to pay your bill.
PAYMENT METHOD: As mentioned above, you are required to keep a valid credit card on your profile. Unless otherwise noted, a credit card is required to guarantee your appointment time but is not charged until you check in for your appointment. If you do not give the required 24 hour cancellation notice or no show, your credit card on file will be charged. Our office accepts only cash and credit cards. No checks are accepted. HSA and FSA cards are honored and any necessary paperwork will be given.
MEDICAL RECORDS: We will provide you a copy of your medical records upon a written/signed request. There is also a nominal fee to process your request. The State of Florida allows for a $1.00 per page charge for the first 25 pages and then $0.25 per page thereafter. Once we receive your request in writing along with the payment, we will process your request within 30 days. As a professional courtesy, if a request is made by another provider, we will provide these electronically at no charge.
FORMS/LETTERS: If you request our office to complete any forms, letters, or accommodation certifications, please note that we do charge for these timely services. The fees range from $20 for a simple letter to $50 for FMLA forms. Once you have made the request in writing, we will inform you of the appropriate fee. Once the payment has been made, please allow 5 business days for completion.
RESULTS: We will happily provide you a copy of all your results of testing that we have ordered. Please be aware that we will follow proper HIPAA compliant instructions that you have provided for communication purposes. Additionally, an office visit is required to review any abnormal results so that a proper treatment plan can be implemented.
BILLING/INSURANCE: Our practice is considered out of network for most of our office visits and services. This means that payment is due at the time of service. We will provide you with any documentation so that you might seek reimbursement. For the services we are able to bill, you hereby authorize us to release any and all medical records required by the insurance company in order to process any claims. Payment of all services are assigned to Dawson Integrative Medical Center, LLC. You also authorize all payment benefits be paid directly to the practice. You understand that you are responsible for any copayments, coinsurance, deductible, and any charges that are not covered by your insurance at the time of service or within 30 days from an insurance denial. You authorize our practice to charge the card you have in your profile immediately for any amount owed to us. For any declined payment or in event there is no valid card on file, you will be mailed an invoice. You will have 30 days to make payment and update your saved credit card on file. Failure to do so may result in dismissal from the practice and you will be sent to collections. You understand you are soley responsibile for any balance due the practice.
FUNCTIONAL MEDICINE/PRIMARY CARE: At this time, our office is considered out of network with insurance for Functional Medicine/Primary Care. Since we spend a considerable amount of time with our patients, most insurance will not appropriately reimburse for our time spent with patients. For this reason, we are considered cash based and afford our patients with attrative self-pay options. If you have insurance, you may be able to utilize it for services we order; such as, but not limited to: laboratory testing at traditional labs (Quest, Labcorp, etc), radiology testing at independent facilities (xray, ultrasound, etc), and certain non-compounded prescriptions. If advanced imaging is necessary (CT Scan, MRI, etc) and your insurance requires a prior authorization, this may have to be referred out or you can opt to pay out of pocket. Our office does not perform or complete prior authorizations of any kind since we are out of network. These services include, but are not limited to: referrals, radiology orders, procedures, and prescriptions. You are able to pay out of pocket and seek reimbursement from your insurance. Compounded medications and weight loss medications are not typically covered by insurance.
ACUPUNCTURE/TCM TREATMENTS: While our office is in network with a select few plans for this service, many plans do not cover all diagnosis and what they do cover, is minimal. For this reason, we do require prepayment at the time of service and then we will submit to your insurance on your behalf. Should insurance not cover acupuncture or TCM modalities, we will accept your prepayment as payment in full. and not balance bill you (unless you have received a treatment above and beyond acupuncture; like injections). There are no credits or refunds issued for any part that insurance does cover, unless they have covered 100% of your visit and all line item charges.
THIRD PARTY BILLING: If you receive a bill from a third party company (laboratory, imaging, etc) and believed you were billed in error or have questions pertaining to this bill, please contact the company or facility directly. Our practice does not have any involvement in billing for services not performed by the clinical staff of our practice.
TREATMENT: You hereby authorize and direct Dawson Integrative Medical Center, LLC to perform medical assessment and treatment upon me. You acknowledge that the practice of medicine is not an exact science and that no guarantee has been made to you as to the outcome of treatment. With your signature below, you grant consent without duress, confusion or pressure from Dawson Integrative Medical Center, LLC. You understand that the information you have provided to this practice is true to the best of your knowledge.
By signing below, you certify and acknowledge that you have read and understand the entire contents of the Office Policies.
We collect PHI from you through treatment, payment and related health care operations, the application and enrollment process, and/or health care providers or health plans, or through other means as applicable. The law specifically protects health information that contains data, such as your name, address, social security number, and others, that could be used to identify you as the individual patient who is associated with that health information. This office may send birthday cards, newsletters and appointment reminders (telephone, text, email, letter, voicemail, etc).
Generally, we may not use or disclose your PHI without your permission. The following are the circumstances under which we are permitted by law to use or disclose your PHI.
As required by law, we may use or disclose your PHI to the extent that such use or disclosure is required by law and that the use or disclosure complies with and is limited to the relevant requirements of such law.
Under HIPAA, you have certain rights with respect to your PHI. It is your right to request the following regarding your PHI:
You may file a complaint with us and with the Secretary of DHHS if you believe that your privacy rights have been violated. Complaints filed with with Secretary of DHHS must be filed within 180 days of when you knew or should have known that the act or ommission occurred.
US Department of Health & Human Services
DHHS (Office of Civil Rights)
200 Independence Ave SW Room 509 Building F
Washington, DC 20201
Certification: My signature below acknowledges that I have read and understand this Privacy Notice relating to HIPAA and PHI.
The process of informed consent is understanding that it is the duty and responsibility of my provider to inform me of risks, benefits, and alternative treatments. Acupuncture is not intended to substitute diagnosis and treatment by a medical doctor or to be used as an alternative to necessary and life saving medical treatment. It is expected that you are under the care of a primary care physician, that pregnant patients are being managed by an appropriate healthcare professional and that patients seeking adjunctive cancer support are under the care of an oncologist.
I understand that the methods of treatment may include, but are not limited to: acupuncture, moxibustion, cupping, electrical stimulation, Gua Sha, Tui-Na, Chinese herbal medicine, nutritional counseling, and acupuncture point injection therapy.
I understand that the herbs may need to be prepared and that the teas consumed according to the instructions provided orally and in writing. Herbs may have an unpleasant taste or smell. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of herbs.
I appreciate that it is not possible to consider every possible complication to care. I have been informed that acupuncture is a generally safe method of treatment, but, as with all types of healthcare interventions, there are some possible risks to care, including, but not limited to: bruising, numbness or tingling near the needling sites that may last several days, dizziness or fainting. Burns, blisters, or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include nerve damage and organ puncture, including lungs. Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.
I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. I will notify the clinical staff who is caring for me if I am, or become pregnant, or if I am nursing. Should I become pregnant, I will discontinue all herbs and supplements until I have consulted and received advice from my acupuncture physician or obstetrician. Some possible side effects of taking herbs are: nausea, gas, stomache, vomiting, liver or kidney damage, headache, diarrhea, rashes, hives, and tingling of the tongue.
If acupuncture point injection therapy is recommended, I understand this is an injection of homeopathic substances into specific acupuncture points on the body in an effort to stimulate a more natural healing process. I have notified the clinical staff of any allergies. The injectables we use are typically adverse event free; however it is not unusual to experience some minor discomfort in the injection area following the procedure. Light bruising, injury to nerves/muscles/blood vessels at the injection site and/or temporary or permanent nerve paralysis most commonly manifested as "tingling."
While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that, as with all healthcare approaches, results are not guaranteed and there is no promise to cure.
I understand that I must inform, and continue to fully inform this office of any medical history, family history, medications and/or supplements being taken currently (by prescription and over-the-counter). I understand the clinical staff may review my patient record and lab reports, but all my records will be kept confidential and will not be released without my written consent.
I understand there are treatment options available for my condition other than acupuncture procedures. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physicial measures and rest, medical care with prescription drugs, physical therapy, bracing, injections and surgery. Lastly, I understand that I have the right to a second opinion and to secure other options about my circumstances and healthcare as I see fit.
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me by the acupuncture physician of Dawson Integrative Medical Center, LLC.
By voluntarily signing below, I confirm that I have read, or have had this read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I agree with the current or future recommendations for care. 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.
FUNCTIONAL MEDICINE INFORMED CONSENT
The main goal of our practice is to implement an Integrative Functional Medicine approach. This addresses underlying causes of disease and symptoms, using an approach that engages both the patient and the provider in an therapeutic partnership. This model works by combining traditional healthcare, nautral/holsistic healthcare and alternative healthcare to offer the best possible outcome. Integrative Functional Medicine is not right for everyone. We work to reverse chronic disease and we focus on prevention and wellness.
Many of our treatment plans will involve the use of supplements or herbs; as many of our patients prefer a more natural approach. When taken at the recommended dosages, supplements and herbs are generally recognized as safe. Occassionally, some minor side effects are common when first beginning anything new; such as digestive upset. Normally, these resolve in time without further issue.
There are risks and side effects involved with taking supplements and herbs. For example, if you are taking a hormonal supplement, you could still experience the same side effects as if you were taking a hormone replacement; such as: bloating, breast tenderness, mood swings, weight gain, trouble sleeping. Although very rare, cardiovascular, blood clots, and cancer risk factors are a possibility whenever dealing with hormones. However, supplementation to balance and promote natural hormones are considered the safest alternative method when compared to traditional hormone replacement therapy.
When and if starting supplements or herbs,
-I will report any undesirable symptoms to my practitioner immediately.
-I will keep my practitioner informed of all medications that I am taking.
-I will keep my practitioner informed of any updates to my medical history.
At this time, our office is considered out of network with insurance for Functional Medicine/Primary Care. Since we spend a considerable amount of time with our patients, most insurance will not appropriately reimburse for our time spent with patients. For this reason, we are considered cash based and afford our patients with attrative self-pay options. If you have insurance, you may be able to utilize it for services we order; such as, but not limited to: laboratory testing at traditional labs (Quest, Labcorp, etc), radiology testing at independent facilities (xray, ultrasound, etc), and certain non-compounded prescriptions. If advanced imaging is necessary (CT Scan, MRI, etc) and your insurance requires a prior authorization, this may have to be referred out or you can opt to pay out of pocket. Our office does not perform or complete prior authorizations of any kind since we are out of network. These services include, but are not limited to: referrals, radiology orders, procedures, and prescriptions. You are able to pay out of pocket and seek reimbursement from your insurance. Compounded medications and weight loss medications are not typically covered by insurance.