Functional medicine is defined as a system of medical thought and practice that focuses on optimal functioning of the whole person, the entire body and its organs, which involves integrating systems of conventional, holistic, integrative, and alternative medicine. In many instances, the treatment plans do not follow standard medical practice because standard medical practice focuses on treating a particular diagnosis or disease process rather than focusing on the individual as a whole. In functional medicine, the focus is on treating the whole person by optimizing the functioning of the body. When deciding to be treated by Root Causes Medicine, there are two main issues to which you will need to agree before treatment will begin. These two issues are patient consent and payment for services rendered.
CONSENT
I hereby request personalized functional medicine evaluation and treatment, based on my own particular health concern and developed partnership with the medical providers at Root Causes Medicine. These treatments may include diagnostic or therapeutic procedures, including various modes of physiotherapy, nutritional therapy (including IV and IM injections if indicated), and diagnostic procedures including laboratory testing on me or the patient named below, for whom I am legally responsible, by the physician or other healthcare providers of Root Causes Medicine, including those other staff members working at the clinic or office.
SCOPE OF PRACTICE
I understand that the healthcare providers at Root Causes Medicine are not traditional primary care providers and do not treat acute medical conditions, nor are they specialists in any field of than functional medicine, and as such will not be treating any specific condition or diagnosis, but rather will be developing a personalized health plan that considers the many aspects of my health and wellness.
PRIMARY CARE
I agree to maintain a relationship with a primary care provider and/or a specialist trained in treating any condition with which I have been previously diagnosed an to abide with the recommended courses of treatment and follow-up schedule as determined by the appropriate guidelines and my primary care provider's or specialist's recommendations.
DISCLAIMER
I understand and I am informed that in the practice of Functional Medicine the conventional medical community considers some therapies and modalities of treatment "investigational," experimental," or "alternative," and that there are some risks to treatment both known and unknown.
Payment
Traditional insurance, including Medicare and private insurance, does not cover the cost of functional medicine consultations or treatments. As a result, you will be required to pay your balance in full at the time services are rendered. Quotes are available upon request, but are subject to change.
Medicare
I will review the Advanced Beneficiary Notice (ABN) from Root Causes Medicine, and agree to sign the ABN and pay the fees charged by Root Causes Medicine at the time services are rendered. If I do not agree with the ABN, I will cancel my appointment prior to services being rendered without penalty.
Private Insurance
Root Causes Medicine and its physicians are not considered providers of private insurance and the patient or their representative: (1) accepts full responsibility for payment of the physician's charge for all services furnished by the physician, (2) understands that no payment will be provided by the patient's insurance for items or services furnished by the physician even if those services are covered by insurance if a proper claim had been submitted, (3) understands that insurance limits to not apply to what the physician may charge for items or services furnished by the physician, (4) agrees not to submit a claim nor ask the physician to submit a claim to the patient's insurance, (5) has entered into this contract with the knowledge that he or she has the right to obtain items and services from physicians who accept private insurance payments, and (6) understands that gap plans or other supplemental plans may not be billed for services.