01 SFM Cash Applicant Disclosures

SFM Cash Only Applicant Disclosures

SFM Disclosures
Date*

MonthDayYear
Date
Applicant Name*

First NameMiddle Name or InitialLast Name
Date of Birth*

MonthDayYear
Date
Acknowledgement 1:*

I understand that completion of these forms for review does not establish a Provider/Patient relationship and does not guarantee acceptance for Sparks Family Medicine's Integrative and Functional Medicine Health Assessment.
Acknowledgement 2:*

I understand that Sparks Family Medicine's Functional Medicine Cash Only Program patients are responsible for a $1,195 payment to include: 1) One office visit including a integrative and functional medicine assessment; 2) One ART session; 3) One follow up visit to address issues from the initial visit and ART session; 4) Additional costs for any specialty laboratory tests; 5) Additional costs for any recommended supplements; 6) Additional costs for services received outside of the three visits identified.
Acknowledgement 3:

I understand that Sparks Family Medicine's Integrative and Functional Medicine Health Assessment is a Cash Only Option. No insurance will be billed. Sparks Family Medicine will collect payment prior to the first visit. The first and second office visits will be in the office, while the third office visit may be online.

Patient Agreement Notice

SFM Disclosure

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Patient Name	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.
Acknowledgement:*

I have read the Patient Agreement Notice.

Integrative and Functional Medicine Notice

SFM Disclosure
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.
Acknowledgement:*

I have read the Integrative and Functional Medicine Notice.

Acute Care Notice

SFM Disclosures
Thank you for your interest in being a patient of Sparks Family Medicine, Ltd (“SFM”). This notice is provided to clarify SFM’s 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.
Acknowledgement:*

I have read the Acute Care Notice.

Applicant Disclosures Acknowledgement

SFM Disclosures
By signing below, applicant or applicant's representative acknowledges that they have reviewed the above SFM Disclosures, (Agreement Notice, Integrative and Functional Medicine Notice and Acute Care Notice), and that they understand and agree to their content.
Date*

MonthDayYear
Date
Applicant Name*

First NameMiddle Name or InitialLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Responsible Party (if not the Applicant)

First NameMiddle Name or InitialLast Name
Relationship to Applicant
Name of Person Signing this Form*

First NameMiddle Name or InitialLast Name
Electronic Signature Acknowledgement and Consent*

I understand and agree that this electronic signature is the legal equivalent of my signature in writing and I consent to be legally bound to this agreement.
Authorization to Receive Password Protected Attachment*

I understand I will receive an email response at the provided email from Sparks Family Medicine, Ltd upon submission of this document with a PDF of the completed agreement attachment. I must use the password "Applicant#1" to open the PDF.
I understand that this is the first of four required forms.*

I will be redirected to complete the Application Health History, Applicant 24-Hour Diet Recall and FM Questionnaires/Evaluations after submitting this form.
Signature*

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SFM Cash Only Applicant Disclosures

Patient Agreement Notice

Integrative and Functional Medicine Notice

Acute Care Notice

Applicant Disclosures Acknowledgement