Dr. Mark Kelley’s New Patient Intake Packet

Dr. Mark Kelley ND, LAc
Naturopathic Doctor and Acupuncturist
209 East Swallow Road
Fort Collins, CO 80525
phone 970.223.7425 Fax 1.866.225.2126

https://www.threeriversnaturalmedicine.com

WELCOME! I am honored that you have chosen me to help in your search for optimum health. This is your New Patient Information Packet. Please read, fill out and sign the attached forms and fax, mail or drop off this packet at least 24 hours prior to your appointment. This allows me and my staff to use your appointment time most efficiently. Bring any prior lab work, supplements, and medicine to your appointment. If you wish to cancel or reschedule your appointment, please notify our office 24 hours or more before your appointment. We charge a fee of one-half of the cost of the visit for missed appointments if less than 24 hours notice is given. It is our office policy to confirm appointments by phone one to two business days before your appointment. If you have an answering machine or voice mail, a message will be left. Many of my patients are sensitive to environmental substances, therefore we ask all patients to refrain from wearing strongly scented hair sprays, colognes, perfumes, aftershaves, etc. on the days you are here. If you have any questions please call our office. I look forward to meeting you!

TRAINING: Dr. Kelley received his pre-medical training with a BA in Psychology from Ohio University. Dr. Kelley then completed his Doctorate of Naturopathic Medicine from Southwest College of Naturopathic Medicine in Tempe, AZ in 2000. This school is an accredited four-year medical program, (4500 hours), specializing in natural therapeutics including basic sciences and clinical training. Dr. Kelley then went on to complete a Masters Degree in Oriental Medicine (2001) from Southwest Acupuncture College, (2643 hours), in Boulder, CO. After passing the naturopathic licensing board exams, Dr. Kelley obtained a license as a Naturopathic Physician in the state of Montana (2001), Arizona (2000) (ret.) and Vermont (2000) (ret.). Dr. Kelley is also a licensed acupuncturist in Colorado (2004) and Montana (2001), Colorado (2014). Dr. Kelley is certified through the National Certification Commission for Acupuncture and Oriental Medicine as a Diplomate in Acupuncture from 8/31/01 to 8/3/17. Dr. Kelley has never had a registration, certificate or license suspended or revoked. Dr. Kelley is continually expanding his education with seminars and workshops several times a year, completing much more than the required continuing education hours. Dr. Kelley is a member of the Montana and Colorado Association of Naturopathic Physicians, the American Association of Naturopathic Physicians, American College for Advancement in Medicine, and American Association of Orthopedic Medicine.

SERVICES: Naturopathic Medicine is a branch of the healing arts distinct from other branches. Our services include the prevention, evaluation, diagnosis, and treatment of injuries, diseases, and conditions through education, nutrition, naturopathic preparations, natural medicines, physical medicine, physical agents, and other therapies and modalities designed to support the body’s natural healing processes. Our Naturopathic Doctors (ND) are registered under the Colorado Naturopathic Doctor Act. They are not Medical Doctors (MD), Doctors of Osteopathy (DO), Doctors of Chiropractic (DC), or Doctors of Nursing (DNP) who are licensed under separate practice acts. As Naturopathic Doctors in Colorado, we do not prescribe, dispense, administer, or inject controlled substances (including general or spinal anesthetics) or practice medicine (including performing surgery, obstetrics, or administering ionizing radiation therapy). The only adjustments, manipulations, and mobilizations we perform are naturopathic manual therapies. We cannot recommend against a course of care recommended or prescribed by a licensed provider in another branch of the healing arts. Our office does not provide naturopathic treatment to children less than two years old. Colorado law requires that we suggest our pediatric patients follow the CDC immunization schedule (copy attached) and have a relationship with a licensed pediatric health care provider, however, myself and many other holistic practitioners do not suggest vaccinations be given to children. The scope of Chinese Medicine includes: acupuncture, needling and injections, Chinese herbs, (bulk teas, fluid extracts and patent formulas), moxibustion, and gua sha. Dr. Kelley may utilize one or a combination of the above listed therapies in working with clients and has trained extensively in combining therapies to meet the health needs of the client.

ALTERNATIVES AND COLLABORATION: Alternatives to Naturopathic Medicine include declining such care and consulting with others such as an MD, DO, DC, or DNP. Naturopathic Medicine is not a substitute for other types of health care and we encourage you to seek second opinions, have a relationship with an MD or DO, to communicate with all your providers about the care recommended in our office, and to authorize us to attempt to collaborate with your other providers. If applicable, please identify the provider with whom we should attempt to collaborate:

RISKS: Naturopathic Medicine is generally considered safe but may involve some risks including, without limit: all of the risks disclosed with any preparations or medicines; allergic reaction; infection; pain or discomfort; weakness, fainting, or nausea; skin irritation, discoloration, or scarring; aggravation of symptoms; mood changes; and rarely, neurological injury and pneumothorax. Naturopathic Medicine may adversely interact with specific drugs and may be inappropriate during pregnancy. Additionally, hidden conditions may exist that are not detectable through examination. This may include spinal tumors, weak or occluded arteries, and aneurysms. Accordingly, some people are at risk for stroke or vascular injuries as a result of manual therapies. This office complies with all rules and regulations promulgated by the Colorado Department of Public Health, including those related to the proper cleaning used in the practice of acupuncture and the sanitation of acupuncture offices. This office uses one-time use disposable needles only. As a client you are entitled to receive information about the methods of therapy, the treatment modalities used, and the duration of therapy if known. As a patient you may seek a second opinion from another health care professional, or may terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the director of the division of professions and occupations in the department of regulatory agencies at: DORA 1560 Broadway, Suite 110 Denver, CO 80202. EMERGENCIES: If you are having a medical emergency, do not wait to seek care. Call 911. NO GUARANTEE: Every individual responds to care differently and no guarantee or assurance is made as to the results of care in any specific case, as care may not improve your condition.

FEE SCHEDULE:
Initial Visit (1 hour) $300
Return visit intermediate (45 minutes) $225
Return visit limited (30 minutes) $150
Return visit brief (15 minutes) $75
Return visit short (5 minutes) $25

PAYMENT REQUIREMENTS: Appointments must be paid for at time of service. I accept Visa, Master Card, check, cash. Please contact our desk for more details. You will be charged a $25 fee for returned checks. All expenses for supplements, herbs, and homeopathic medicines are in addition to the cost of the treatment. I take great care, and am able with my education, to discern quality and potency. I use physician-only lines of supplements that are what they say they are, and that are designed to be very potent and therefore only used by physicians. These companies were created by doctors like me for doctors like me that “know the difference” and they cater to my particular, critical and demanding standards. Further, they often make available substances that only doctors like me know to use, and that the lay market does not know, understand and therefore demand so that they are not found in the lay market. I am able to use quality, potent materials that produce dramatic results for people working to improve their health. This is vital to the success of my patients.

APPOINTMENTS: We require 24 hours notice if you need to change or cancel your appointment. You will be charged a fee of 50% of the total cost of any missed appointment if the 24 hour advance cancellation policy was not met. RECORDS: I will keep a record of your health care. I will not disclose your record to others unless you direct us to.

INSURANCE AND MEDICARE: I have no accounts with insurance companies, but we will give you a superbill you can submit for insurance reimbursement if you ask at the appointment. Remember, payment is expected at time of service and any insurance payments will go directly to you. I am unable to bill Medicare/Medicaid! Medicare will not reimburse you for services rendered with me and you should not seek reimbursement from Medicare.

I have read the above information and my signature endorses my understanding of these conditions.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT
Dr. Mark Kelley, ND
209 E Swallow Rd Fort Collins, CO 80525

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.