Conditions for subscription
· Each subscriber must comply with subscription requirements, by being honest about medical history, remitting monthly payments, attending mandatory free visits each calendar year.
. Level I and II - 1 free visit per year Level III-2 free visits per year
. Each subscriber must attend 1 nutritional assessment per year.
. Smokers must receive nonsmoking educational materials and attempt nonsmoking treatments offered and attempt to meet a goal of no smoking within 12 to 24 months.
. Opioid and alcohol addiction subscribers MUST attend counseling sessions prior to receiving treatment/prescriptions and attempt a goal of sobriety within 12 months.
. Subscribers must submit to drug testing for ongoing addiction treatment.
. Subscribers are strongly encouraged to do physical activity as deemed appropriate. For subscriber's receiving mental health services, physical activity as deemed appropriate is mandatory.
Conditions for termination:
Aggressive or inappropriate behavior toward staff and other patients.
Fraudulent behavior or medical history
Noncompliance with conditions for subscription without a waiver from CMO.
Nonpayment for 90 days without arrangements.
ACCEPTANCE AND TERMINATION OF SUBSCRIBER CONTRACTS ARE AT THE SOLE DISCRETION OF THE CMO.
Our office focuses on wellness and preventive health goals. There is no "on call" service. If subscriber has an urgent or emergent medical occurrence, it is the subscriber's responsibility to present to urgent care, nearest emergency department or call 911.
I give my permission to be treated at this facility.
I agree with the above statements and attest to this agreement with my electronic signature below: