SFM Updated Disclosures

Sparks Family Medicine, Ltd ("SFM") occassionally updates forms on file for patients. Please read the following disclosures, agreements and consents to make sure you understand the policies of SFM and to update contact information on your account. Copies of this document will be kept in your patient chart. Thank you for your assistance in updating these forms.

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Patient Name	Patient Date of Birth	Date Completed

 

Sparks Family Medicine, Ltd offers patient agreements for patients who want access to integrative and functional medicine. Patient agreements provide the terms, benefits, payments patient responsibilities, changes and termination requirements. Patients who agree to execute a patient agreement should be aware that:

1.      Payments for the patient agreement services are processed up to three days prior to the patient’s initially scheduled appointment, are nonrefundable and require a credit card for recurring payments.

2.      There may be additional costs for accessing patient agreement services, including but not limited to specialty laboratory testing, supplements and prescriptions.

3.      Patients are responsible for accessing patient agreement services, providing payment for services when due, updating contact information and terminating the patient agreement prior to scheduled payments.

Patient agreements are available for review by prospective patients in the office during normal business hours. Due to the proprietary nature of the agreements, patient agreements are not provided to prospective patients outside of the office. Prospective patients are not allowed to keep blank patient agreements. Patients will receive a copy of the executed patient agreement after their first office visit.

Unless explicitly stated in the patient agreement, patient agreements do not cover fees for office visits. Fees for office visits are due at the time of service or will be billed to insurance if Sparks Family Medicine is an in-network provider. Patient is responsible for all payments required by their insurance agreement, including co-payments, deductibles and cost-sharing.

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Patient Name	Patient Date of Birth	Date Completed

Specialty Lab Tests
Sparks Family Medicine (“SFM”) utilizes a variety of specialty lab tests that may or may not be covered by insurance. Payment for the specialty lab tests and phlebotomy services are the responsibility of the patient and are made directly to the laboratories. These costs are in addition to SFM's office visit and functional medicine program fees. Patients are under no obligation to purchase the specialty lab tests recommended by SFM. SFM does not profit from specialty lab tests.

Nutritional Supplements
SFM provides nutritional counseling and makes individualized recommendations regarding use of vitamins, minerals, trace elements, amino acids, herbs and homeopathic remedies (“nutritional supplements”) in order to upgrade the quality of nutrition in a patient's diet and to supply nutrition to support the physiological and biomechanical processes of the human body. Although these products may also be suggested with a specific therapeutic purpose in mind, their use is chiefly designed to support given aspects of metabolic function. Use of nutritional supplements may be safely recommended for patients already using pharmaceutical medications, but some potentially harmful interactions may occur, so it is important that patients keep their healthcare providers fully informed about all of the medications and nutritional supplements they are taking. SFM recommends quality nutritional supplements that tend to produce predictable results.

SFM may profit from making nutritional supplements available to purchase in the office and from online vendors. SFM does not set the prices of nutritional supplements sold or recommended. Patients are welcome to discuss the use of nutritional supplements with SFM providers. Patients are under no obligation to purchase nutritional supplements from SFM or from SFM vendors.

Adjunct Therapies
Integrative and Functional Medicine (“I&FM”) addresses the underlying cause of dysfunction and disease, including inflammation and stress. To reduce inflammation, increase relaxation and assist the limbic system, Sparks Family Medicine, Ltd. (“SFM”) offers patients access to adjunct therapies including but not limited to Reiki, light therapy, energetic assessments and red light therapy. These adjunct therapies have been shown to reduce inflammation, increase relaxation and/or assist the limbic system. As each patient is unique, SFM makes no guarantee that use of adjunct therapies will reduce inflammation, increase relaxation and/or assist the limbic system to achieve the desired benefit from using adjunct therapies. 

Patients choosing to utilize adjunct therapies agree as follows:

1. I understand that reactions are rare, but may include nausea, dizziness, weakness and possible skin reactions including redness and/or other irritations.
2. I understand that I should not have certain adjunct therapies if I am pregnant or may become pregnant.
3. I understand that if I have photosensitivity or epileptic seizures, am currently taking medications that are known to increase skin sensitivity to light or are heat sensitive, I should discontinue adjunct therapies if it aggravates these conditions.
4. I understand that while I&FM supports the use of certain adjunct therapies, traditional physicians may not agree that the use of these adjunct therapies will reduce inflammation, increases relaxation, assist the limbic system or offer any health benefits.
5. I understand that adjunct therapies are optional and I may discontinue them at any time.
6. I acknowledge before utilizing any adjunct therapy, I will have sufficiently discussed any concerns or questions regarding adjunct therapies with my SFM provider.

{patientName378}	{dateOf380}	{date}
Patient Name	Patient Date of Birth	Date Completed

 

This notice is provided to clarify Sparks Family Medicine, Ltd (“SFM”) role in patient care and to manage patient expectations related to their care at SFM. SFM patients should know the following:

·       SFM provides primary care for chronic health care problems.

·       SFM has limited appointment availability and does not accept walk-in appointments.

·       SFM does not provide acute care or urgent care.

·       SFM refers patients to acute care, the emergency room or insurance resources (on-call nurses) for after-hours care.

Based on the care available at SFM, SFM strongly recommends that patients maintain a relationship with another primary care office or quick care facility for acute care and urgent care.

In an acute care or urgent care situation, the cost of care is typically less at acute care and urgent care providers than the emergency room. If patients haven’t established and maintained a relationship with an acute care or urgent care provider, acute care and urgent care access may be limited, especially after-hours. It is important that patients have an established relationship with an acute care or urgent care provider to avoid the additional cost of having to use the emergency room for issues that could be treated in another setting.

Insurance companies and healthcare systems may provide triage services to help patients determine the severity of symptoms and the level of care required. If in doubt, please call 911 or seek care at the nearest urgent care or emergency room.

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Patient Name	Patient Date of Birth	Date Completed

 

To comply with state and federal law concerning the disclosure of protected health informatoin (PHI), Sparks Family Medicine, Ltd. requires that you indicate how PHI should be communicated to you or your personal representative. SFM provides a secure patient portal for the exchange of messages and documents. The patient portal is the default method of sharing PHI between SFM and you.

For your convenience, please indicate if you would like to OPT IN to having your PHI, such as lab results, imaging studies, visit follow ups), communicated to you using the following methods. I understand that the PHI disclosed will be minimal, such as first name, the name of our office, results of either "normal" or "abnormal", basic treatement result data), appointment dates and times, and our contact information.

Your portal email and preferred contact phone will be used.

Your rights as outlined in the Notice of Privacy Practices provided to you by this office are still protected, regardless of how you choose for PHI to be communicated to you or your personal representative. This consent will remain in effect unless changed, in writing, by you our your personal representative.

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Patient Name	Patient Date of Birth	Date Completed

 

Sparks Family Medicine, Ltd. accepts payment in the form of cash, check and most credit cards. Sparks Family Medicine requires payment when services are rendered. Patients covered by an insurance plan with an established responsibility are responsible for payment prior to being seen. Patients with patient responsibility based on charges will be required to pay after receiving services. Sparks Family Medicine reserves the right to refuse care to patients with outstanding patient responsibility until this financial obligation is met. Sparks Family Medicine is not an urgent care or emergency care facility.

Sparks Family Medicine will submit a claim for services rendered based on the insurance company on file for the patient. If the insurance company on file does not process the claim, the claim will be resubmitted a second time. If the insurance
company requests information from the insured, please submit this information as soon as possible. After two claims have been submitted to the insurance company on file, any outstanding balance will be billed to the responsible party. After two patient statements, any outstanding balance may be turned to a collection agency.
Sparks Family Medicine charges the following fees that will be added to the patient's account balance. These fees may be amended as clearly displayed in the patient waiting room.

1. A $25 fee for all returned checks.
2. A collection fee of 35% of the outstanding balance with a $20 minimum fee.
3. Sparks Family Medicine reserves the right to charge a missed appointment fee of up to $100 for missed appointments and appointments canceled with less than two business days notice.

Summary of billing process:
1. We will file an insurance claim for services provided or collect payment at time of service.
2. The insurance company on file is required to make a prompt payment to our office.
3. You will receive an Explanation of Benefits from the insurance company showing the balance owed to our office, if any.
4. We will attempt to send the responsible party two statements showing the outstanding balance. If a statement is returned as undeliverable, the account may be turned to a collection agency with a collection fee of 35% of the outstanding balance with a $20 minimum fee.
5. Any outstanding balance will be turned to a collection agency with a collection fee of 35% of the outstanding balance with a $20 minimum fee.

{patientName378}	{dateOf380}	{date}
Patient Name	Patient Date of Birth	Date Completed

 

The responsible party is financially responsible for all charges made to the patient's account whether or not an insurance company is involved in payment. The responsible party is responsible for all co-payments, co-insurance, non-covered supplies and services, and yearly deductibles. The responsible party is also responsible for collection fees, legal fees and other fees incurred by Sparks Family Medicine in efforts to receive payment of financial obligations for services rendered.

The responsible party is responsible for providing proof of current insurance coverage and photo identification at the time of service if Sparks Family Medicine is to submit insurance claims to an insurance company. The responsible party will be responsible for charges incurred if current insurance coverage is not correctly established at the time of service.

The responsible party is responsible for contacting their insurance to verify the participation of the providers of Sparks Family Medicine with their insurance plan using Sparks Family Medicine's Tax ID of 88-0477868 prior to providing health insurance information to Sparks Family Medicine. 

The responsible party is responsible for updating any changes in personal information, including insurance coverage, in order to facilitate the timely filing and processing of all insurance claims. The responsible party is responsible for responding to requests for additional information from an insurance company in a timely manner. Failure to update personal information at the time of service or failure to provide addiction information to an insurance company will result in the responsible party being charged for services rendered. The responsible party is responsible for facilitating the processing of insurance claims by providing information requested by insurance companies, contacting insurance companies to resolve incorrectly processed claims, and monitoring the processing of insurance claims. Insurance companies are required to send and explanation of benefits for every claim submitted to them.

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Patient Name	Patient Date of Birth	Date Completed

 

Sparks Family Medicine, Ltd. providers try to address patient concerns at office visits. Patients should be prepared for office visits, including providing the names and dosage of current medications and supplements.

Sparks Family Medicine providers may refer patients to specialists, laboratory and imaging services, and other services. Patients have the right to collaborate with their provider on the vendors providing the referral services. Patients should verify that ALL vendors participate with their insurance, if applicable. Patients may decline to receive these services.

Sparks Family Medicine providers may prescribe medication. Patients have the right to understand the risks and benefits of the medication prescribed and to discuss their concerns with their provider. Sparks Family Medicine providers may recommend speciality laboratory testing, nutritional and herbal supplements, complementary and alternative medical services (CAMs) and/or adjunct therapy. Patients have the right to decline these services.

1. I understand that I have the right to decline referrals, services, medication and products.

2. I understand that I have the right to discuss my objective and concerns with my provider.

3. I understand that I am responsible for verifying the participation of vendors—labs, imaging centers, specialits, etc.—with my insurance, if applicable.

4. I understand that I am urged to schedule a follow-up appointment for all ordered tests.

5. I understand that my SFM provider and I are in a collaborative relationship focused on my health, including preventive, Integrative and Funcitonal Medicine options.

6. I understand that I have the right to be treated with respect and courtesy by the SFM staff and providers. I understand that I am expected to treat the SFM staff and providers with respect and courtesy.

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Patient Name	Patient Date of Birth	Date Completed

 

“Telemedicine” allows for patient evaluation and treatment by a health care provider from a distant location via electronic communication, including but not limited to video chat and telephone. It is important you understand and agree to the following about telemedicine:

• The consulting health care provider will be at a different location from me. Additional personnel may also be present in the room with the provider. HIPAA regulations still apply to telemedicine.

• I understand that my voice and image may be recorded in order to assist the medical or registration personnel and I consent to any such audio and video recording.

• I understand there are potential risks to this technology, including, but not limited to, interruptions, unauthorized access, technical difficulties, and call termination.

• I understand that my health care provider or I can discontinue the telemedicine consultation if it that the electronic communication is not adequate for my situation.

• I understand that there are limitations to this type of care. I understand it is my responsibility to communicate my conditions and symptoms and to seek care from other providers as directed.

• I understand that I am responsible for services if all or some of my consultation with provider by telemedicine is not covered by my insurance.

Authorizations

• I grant permission for Sparks Family Medicine providers to perform and administer care and treatment of the patient via telemedicine/telehealth.

• I grant permission to release to third party payor(s) (such as Medicare or private insurance companies), their representatives, and/or other physician(s) involved in the patient's care, any information needed in connection with all care rendered to patient.

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Patient Name	Patient Date of Birth	Date Completed

 

This agreement protects your access to controlled substances and to protect our ability to prescribe for you. The long-term use of such substances as opioids (narcotic analgesics), benzodiazepine, tranquilizers, and barbiturate sedatives is controversial because of uncertainty regarding the extent to which they provide long-term benefit. There is also the risk of an addictive disorder developing or of relapse occurring in a person with a prior addiction. Because these drugs have potential for abuse or diversion, strict accountability is necessary when use is prolonged. For this reason the following policies are agreed to by you, the patient, as consideration for, and a condition of, the willingness of the physician to consider the initial and/or continued prescription of controlled substances to treat your chronic pain.

1. All controlled substances must come from the patient's primary physician or, during his or her absence, by the covering physician, unless specific authorization is obtained for an exception. (Multiple sources can lead to untoward drug interactions or poor coordination of treatment).

2. You are expected to inform our office of any new medications or medical conditions, and of any adverse effects you experience from any of the medications that you take.

3. The prescribing physician has permission to discuss all diagnostic and treatment details with dispensing pharmacists or other professionals who provide your health care for purposes of maintaining accountability.

4. You may not share, sell, or otherwise permit others to have access to these medications.

5. Unannounced, random urine or serum toxicology screens may be requested, this will be at the patient's expense and your cooperation is required. Presence of unauthorized substances may be subject to discontinuation of medication and/or termination from care effective immediately.

6. Prescriptions and bottles of these medications may be sought by other individuals with chemical dependency and should be closely safeguarded. It is expected that you will take the highest possible degree of care with your medication and prescription. They should not be left where others might see or otherwise have access to them.

7. Since the drugs may be hazardous or lethal to a person who is not tolerant to their effects, especially a child, you must keep them out of reach of such people.

8. Medications may not be replaced if they are lost, get wet, are destroyed, left on an airplane etc. If your medication has been stolen and you complete a police report regarding the theft, an exception may be made.

9. Early refills will generally not be given.

10. If the responsible legal authorities have questions concerning your treatment, as might occur, for example, if you were obtaining medications at several pharmacies, all confidentiality is waived and these authorities may be given full access to our records of controlled substances administration.

11. It is understood that failure to adhere to these policies may result in cessation of therapy with controlled substance prescribing by this office and referral for further specialty assessment.

12. Precription renewals are contingent on keeping scheduled appointments and completing the required controlled substance paperwork. Please do not phone for prescriptions after hours or on weekends.

13. The risks and potential benefits of these therapies will be discussed between you and your provider. 

{patientName378}	{dateOf380}	{date}
Patient Name	Patient Date of Birth	Date Completed

 

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

I acknowledge that online access to the Notice of Privacy Practices from Sparks Family Medicine, Ltd. has been provided to me. I understand that I may request a copy of the Notice of Privacy Practices. I also understand that any concerns about protected health information should be directed in writing to:

Sparks Family Medicine, Ltd.

Attn: Office Manager

410 South Rampart, Suite 390

Las Vegas, NV 89145

Contact@sparksfamilymedicine.com

By signing below, applicant or applicant's representative acknowledges that they have reviewed the above SFM Disclosures, (Agreement Notice, Specialty Lab Notice, Nutritional and Herbal Supplement Notice, and Acute Care Notice), and that they understand and agree to their content.