Musculoskeletal Consult Consent Form

This form is for patients interested in a Musculoskeletal Consult at 919 Spine to discuss PRP, Trigger Point & Joint Injections, and Regenerative Medicine. Your consult will be performed by a licensed provider of The Functional Medicine Center within the office space of 919 Spine.

We hope you will answer the questions on this medical history form as thoughtfully as possible. Please consider this an opportunity to write anything you think may be pertinent to your condition. ALL THE INFORMATION IN THIS QUESTIONNAIRE IS CONFIDENTIAL BY LAW.

If you do not have all your X-rays, MRIs, CT Scans (both images and reports), please start collecting those from other providers you have seen. They are vital in guiding you appropriately.

Today's Date*

Date

What is your name?*

First NameLast name

Date of Birth?*

Your date of birth

Gender Identity?

M/F/transgender M/ transgender F/decline to specify

Preferred Pronoun(s)

Nickname

What is Your Home Address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is your phone number?*

Email address?*

Email Address

Emergency Contact: name and phone

Please pick smoking status from drop down menu

How did you hear about us?*

Which Procedure Are You Most Interested In Considering During Your Consult?*

Anti-Inflammatory Trigger Point or Joint InjectionPRPRegenerative Injection (Stem Cells)Other

What is the reason for today's visit? Please include when any problems began. Be sure to include dates of consultations with other providers, x-rays, MRIs. Please include as many details about your condition as possible, even if it seems unimportant.*

Height

Weight

Allergies to Medication? Please include what reaction you have.

Allergies to Foods?

Current Medications and Supplements including condition you take them for:

Please list name, street address (including zip code), and phone number of your preferred PHARMACY for PRESCIPTIONS. *This will be saved to your chart*

I hereby certify that the above information is true and accurate to the best of my knowledge.

Thank you for choosing The Functional Medicine Center (TFMC). We are committed to providing you with the best possible understanding of our financial policy is important to our professional relationship. We make every effort to keep our fees covering the cost of the services we provide. In order to keep healthcare costs to an absolute minimum, we have adopted

1. DOES TFMC TAKE HEALTH INSURANCE?
We have opted not to participate in any health insurance plans. Even if your services with 919 Spine are covered through your insurance, services rendered by TFMC are separate.

2. MUSCULOSKELETAL PATIENT COSTS
a. Each consult is billed at a cost of $250. This includes review of outside records pertaining to your complaint, exam, and discussion of all options we may be able to provide. You will be charged this fee at the time you schedule your visit.

3.CANCELLATION POLICIES AND FEES
a. Please be advised: 48-hour notice is required when rescheduling a Musculoskeletal Consultation appointment
b. Missing your Musculoskeletal Consultation visit with no notice or less than 48 hours notice will result in forfeiture of your consult fee.

4. LATE PAYMENTS
a. Late Fee: If your account is 10 days late, you will be subject to $100 fee per 10 day period of lateness.
b. Collections Charge: Accounts that are not paid within 60 days from due date may be sent to an External Collection Agency and will be subject to a 33% surcharge to cover our costs.

MEDICARE ADVANCE BENEFICIARY NOTICE (this section only applies if you have Medicare)

This private contract agreement is between Joshua Corwin, The Functional Medicine Center and beneficiary noted below. The beneficiary is a Medicare Part B beneficiary and is seeking services covered under Medicare Part B. The provider above has informed the beneficiary or his/her legal
representative they have opted-out of the Medicare Program. The current Medicare opt-out period is from 10/1/2023 to 10/1/2025. The physician noted above is not excluded from participating in Medicare Part B under §§1128, 1156 or 1892 of the Act.

I or my legal representative accept full responsibility for payment of charges for all services furnished by The Functional Medicine Center.

I or my legal representative understand that Medicare limits do not apply to what Joshua Corwin or The Functional Medicine Center may charge for items or services furnished.

I or my legal representative agree not to submit a claim to Medicare or to ask The Functional Medicine Center to submit a claim to Medicare.

I, or my legal representative, have been informed of the expected or known expiration date of the opt-out period; which is 10/1/23 to 10/1/2025

I or my legal representative understand that Medicare payment will not be made for any items or services furnished by The Functional Medicine Center that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.

I or my legal representative enter into this contract with the knowledge that I have the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not opted-out of Medicare, and I am not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.

I would like to become a patient of The Functional Medicine Center and have my musculoskeltal consult performed at 919 Spine.

I agree that all charges and fees listed include a credit card fee of approximately 3.3%.

The Functional Medicine Center may contact me via SMS (Text Message) in response to my form. Privacy Policy is available to review at https://thefunctionalmedicinecenter.org/privacy-policy. By checking this box, you agree to receive SMS from The Functional Medicine Center

Please sign your name with touch screen or mouse if completing at home. All data on this form is encrypted and is transmitted securely via SSL.*

Musculoskeletal Consult Intake Form

Financial Policy for Musculoskeletal Consult

Please read and sign below