CAROLINA

All in One Waiver Form and Intake Forms

Carolina Holistic Medicine (Short Form)

Phone: Cell: () Gender: [ ] Male [ ] Female

In Case of Emergency, Contact:

Please list the three major reasons you are seeking consultation at this point in time:

APPOINTMENT CANCELLATION / NO SHOW POLICY

Thank you for trusting your care to Carolina Holistic Medicine. When you schedule an appointment with Carolina Holistic Medicine, we set aside enough time to provide you with the highest quality care. In our efforts as a low volume practice, which blocks a set time in our schedule for you to receive high quality care, we now require a non-refundable deposit to hold your appointment on our calendar. Please see our Appointment Cancellation / No Show Policy below: Effective September 25, 2024, a non-refundable deposit in the amount of $200.00 will be required for all new patients and any patient not on a care plan. This non-refundable deposit will be paid at the time of scheduling your appointment. If you reschedule, cancel, and/or no-show for your appointment, you will lose this deposit and, further, will be required to pay-in-full for any subsequent appointments. We understand that there may be times when an unforeseen emergency occurs, and you may not be able to keep your scheduled appointment. If you should experience such extenuating circumstances, please contact our office as soon as possible. Such cases will be given special consideration and reviewed on a case-by-case basis by Dr. Saleeby and/or Sharon Saleeby. Please note that there are no guarantees that the non-refundable deposit will be reimbursed, but it will be given appropriate review and consideration.

I have read and understand the Appointment Cancellation / No Show Policy and agree to its

Cancellation Policy/ Payment / Insurance

Medicare/ CMS Opt Out Texting/email allowance waiver I understand that by visiting and consulting with Priority Health Healing Ministry dba Carolina Holistic Medicine (CHM), Dr. Saleeby and all contracted Advanced Providers (NP/PA) are practicing the new paradigm in medicine under what can be described Integrative or reformed-Functional Medicine. This means we subscribe to a different Evidence Based Medicine paradigm than what is currently considered the standard care in Allopathic mainstream Western Medicine. Therefore, we may not limit ourselves to current Practice Guidelines and may implement a blend of conventional medicine with evidence- based complementary/integrative therapies. By signing this waiver, I fully understand and agree to proceed. Our practice also operates as a Private Membership Association (PMA) and a 508c1A organization. By signing this agreement you become a member of our PMA and additionally that of The Body Healthcare (TBH aka The Body) and possibly the First Nation Turtle Healing Band PHA.

(1) Office visits / Payment / Membership (Care Plans) / Insurance / Records and Rx information (please review all sections; by signing you acknowledge you have read and understand these forms Office Visit I Especially for your first office visit, arrive 20-minutes before your designated appointment to complete check-in process. We try to adhere to a no-wait policy, so if you are late it will delay others and your visit will be adjusted in duration or you will be rescheduled. Visit time is dependent on your chief complaint(s) or reasons for visit, they will be scheduled appropriately. No-Show Policy I Appointments must be canceled at least 72 business hours as a curtesy prior to the scheduled appointment time for existing patients (new patients forfeit their deposits No-shows (N/S) are unacceptable. Non-refundable deposits are as described. They are non-refundable. Repeated N/S or cancellations will result in dismissal from the

If on a Healthcare Membership PLAN a visit will be used in place of a deposit or fee. Repeated no-shows will result in a termination of the provider/patient relationship. The deposit will be collected at time of appointment to secure and hold your block of time with provider(s (Not applicable with some membership plans) ALL new patients are required to pay a $200 deposit to hold an appointment. That will be forfeited if you do not adhere to our policy. This is a non-refundable deposit. Payment I Payment is due at the time service is rendered. We accept cash, checks, money orders, and most major credit cards. Checks are payable to Priority Health Healing Ministry and is considered tax exempt (non-profit status) or Carolina Holistic Medicine. Unresolved or delinquent balances may be placed with an outside collection agency and may also be subject to finance charges, attorney fees, and collection agency fees. If you are due to be on membership you have until the end of that business day to sign up or face the Fee-for- Service (Cash-for-Care) fees associated with that visit. As a membership practice you may be better served to be on one of our care plans. It is optional but will become mandatory after January 1st, 2025. It does provide some additional benefits not seen with Fee-For-

Since January 1st, 2015, we no longer file health insurance claims, we are a direct pay practice and will provide you documentation to help you file for reimbursement through your insurance company (excluding Medicare as that is not allowed Patients on membership care plans cannot submit for insurance reimbursement, however costs may be reimbursable through some HSA plans. Total Payments to our NGO may be tax deductible and ask for a letter stating the total spent for the year for your accountant. (Patients will need to confirm eligibility through their individual plans We can prorate quarterly your membership fees on a Superbill. Insurance I Please bring your photo ID (e.g. Driver's License) and your current insurance ID card and Prescription Card if available to each visit. We may need to provide this information to 3rd party vendors who do file insurance claims. Make sure you update us if these change.

We currently are OUT-OF-NETWORK providers with all insurance carriers. This also included Medicare (CMS) and Medicaid.

Insurance info is important for Lab processing. Medication Plan info is important so if you have it please provide us. By signing this waiver you consent to this and understand. Bring all your medications and non-prescription remedies (supplements) in their original bottles (or printed out on paper) with you to your first appointment so we can accurately review your regimen. This will help our nurse keep an accurate Medication List for you in our Electronic Health Record. You also must note the name of the physician(s) who prescribed each medication if not by us. If you do not have this list, your appointment may be

We will not renew or refill prescriptions by phone unless you are on a PLAN and have no balance due. During each office visit, be prepared to tell the provider what you need to ensure that your medications refills do not lapse. Refill requests should be submitted to our offices by your pharmacy. Our prescription nurse will address all emails, faxes or E- Requests for refills sent from the pharmacy. Please do not call. The email for specialty refills is inursing@carolinaholisticmedicine.com this Inbox is monitored twice per day (Monday-Thursday by 4PM) and all requests are presented to providers for approval. Refills may take 48-72 hrs. during business days to process. Note that neither scheduled drugs (opiates, benzos) nor antibiotics are routinely called in to the pharmacy without an office visit or telehealth visit. We do not generally refill Rx after Thursday afternoon after 4PM until next working day (Monday We also have a Opioid/Scheduled Drug policy that limits the Rx of these classes of drugs. Lab Results and Other Results I All test results are reviewed by each ordering provider (and overseen by Dr. Saleeby) before they are signed-off & filed. If any significant findings are noted, you will be contacted by a member of our staff. We ask that you DO NOT call us for results. Likewise, DO NOT ask us to explain the results by phone, text, email or by fax. Such matters will only be addressed at scheduled office or telehealth appointments. Please

review our Patient Handbook for further details.

(2) NOTICE OF HEALTHCARE PRIVACY PRACTICES AT PRIORITY HEALTH, LLC

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully. We Have a Legal Duty to Safeguard Your Protected Health Information (PHI): We are legally required to protect the privacy of health information that may reveal your identity. This information is commonly referred to as protected health information, or PHI for short. It includes information that can be used to identify you that we have created or received about your past, present or future health or condition, the provision of health care

to you, or the payment of this health care. We must provide you with this notice about our privacy practices that explains how, when and why we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. We are legally required to follow the privacy practices that are described in this notice. We reserve the right to change the terms of this notice and our privacy policies at any time. Any changes will apply to the PHI we already have. Before we make an important change to our policies, we will promptly change this notice and post a new notice. You can also request a copy of this notice at any time from our office/practice manager by calling our

How We May Use and Disclose Your Protected Health Information: We use and disclose health information for many different reasons. For some of these uses or disclosures, we need your prior consent or specific authorization. Below we describe the different categories of our uses and disclosures and give you some examples of each

During your intake, prior to receiving any health care services, you will be asked to sign a statement permitting Priority HEALTH (dba Carolina Holistic Medicine) and its medical staff to release your health information for purposes of Treatment, Payment and Health Care Operations. A description of each of these uses is described as follows. Uses and Disclosures Relating to Treatment, Payment or Health Care Operations. We may use and disclose your PHI for the following reasons: For treatment. We may disclose your PHI to physicians, nurses, medical students, and other health care personnel who provide you with health care services or are involved in

We may use and disclose your PHI in order for you to collect payment for the treatment and services provided to you. For example, we may provide portions of your PHI to our billing department and your health plan to get your claims processed for the health care services we provided to you. We may also provide your PHI to our business associates, such as billing companies, claims processing companies and others that process our health care claims or provide services on our behalf, or provide services directly to you. For health care operations. We may disclose your PHI in order to operate our health care delivery system. For example, we may use your PHI in order to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided health care services to you. We may also provide your PHI to

our accountants, attorneys, consultants and other in order to make sure were complying

To the extent we are required to disclose your PHI to contractors, agents and other business associates who need the information in order to assist us with obtaining payment or carrying out our business operations, we will have a written contract to ensure that our business associate also protects the privacy of your PHI.

More information is available at:

htps://www.hhs.gov/hipaa/for-individuals/index.html We also have a printed HIPAA poster at each of our offices

(3) Advance Beneficiary Notice of Non-coverage (ABN) This no longer applies as we are OUT OF NETWORK with all Health Insurance programs INCLUDING Medicare. You may need to sign this on labs you order with your insurance plan

Lab Vendor will obtain this ABN.

I the undersigned or Representative, do agree and consent to all medical treatments and services provided by Dr. Yusuf (JP) Saleeby, MD, his staff and practitioners at Priority Health Healing Ministry DBA Carolina Holistic Medicine (CHM Medical services are defined as any and all diagnostics and treatments. Providers on our team may include several Nurse Practitioners and Physician Associates. This includes but is not limited to exercise programs, medicinal treatments, herbals, medical foods, pharmaceuticals, and alternative therapies, drug therapy, IV infusion therapy. I further understand that Dr. Saleeby and Priority Health Healing Ministry & CHM do not offer Emergency services and the practice deals with specialized diagnostics and protocols. If an emergency care need arises, I realize I must go to the nearest emergency medical facility (ER) or call 9-1-1 for treatment of life or limb threatening situations. We are a supergeneralist practice reformed Functional

| agree to hold harmless and indemnify Dr. Saleeby, the staff and professionals at Priority Health Healing Ministry & CHM from any and all claims involving the medical services provided. I further understand that Dr. Saleeby and the providers do not guarantee results and results of therapy vary from patient to patient. I understand that successful treatment with Dr. Saleeby's and staff recommendations is primarily based on my own decisions and life choices and compliance /adherence to the plan /program. I further understand that the

practice offers Alternatives to conventional medicine often referred to a complimentary medicine, CAM, Integrative, Functional Medicine and by other names such as natural or organic medicine, which may have not been approved by the FDA. This practice does not necessarily abide by the conventional practice guidelines and our patients must be aware

I understand by signing this waiver and becoming a member of the Private Membership Association I will abide by the points in this membership and agree to the details of

mediation/arbitration within our PMA.

I agree that payment is considered due in full at the time of services or upon invoice. Payment may be made by cash, credit card/debit card, check or certified check.

Iunderstand that Priority Health/CHM and its providers are OUT-OF-NETWORK providers

with all insurance plans. I also will adhere (if applicable) to all conditions of the practice & providers practicing at Carolina Holistic Medicine opting out of Medicare and Medicaid. We secure non-refundable deposits for initial (new patient) and follow up appointments for non-membership patients. Pursuant to HIPAA act of 1996, should I have any questions regarding the privacy of my

facility may use and disclose my health information I will visit: https://www.hhs.gov/hipaa/for-individuals/index.html for more

(5) Special Medicare Opt-Out Waiver (only applies for those with Medicare) This private contract agreement is between the physician and beneficiary noted above. The beneficiary is a Medicare Part B beneficiary and is seeking services covered under Medicare Part B. The physician 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 the date of signing for one full year (12-months The physician noted above is not excluded from participating in Medicare Part B under $$1128, 1156 or 1892 of the Act. The beneficiary or his/her legal representative has read and agree to the following terms of the private contract by placing their initials by the items below: I, or my legal representative, accept full responsibility for payment of the physician's or practitioner's charge for all services furnished by this physician/practitioner; I, or my legal representative, understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner;

I, or my legal representative, agree not to submit a claim to Medicare or to ask the physician/practitioner 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 to a full 12-months after signing this document; I, or my legal representative, understand that Medicare payment will not be made for any items or services furnished by the physician/practitioner 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 the contract with the knowledge that the beneficiary has the right to obtain Medicare- covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is 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, or my legal representative, understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by

I, or my legal representative, agree this contract was not entered into during a time when the beneficiary required emergency care services or urgent care services.

I, the Medicare beneficiary or my legal representative accept full responsibility for payment of charges for all services furnished by Carolina Holistic Medicine. I, the Medicare beneficiary or my legal representative understand that Medicare limits do not apply to what Carolina Holistic Medicine may charge for items or services furnished. I, the Medicare beneficiary or my legal representative agree not to submit a claim to Medicare or ask Carolina Holistic Medicine to submit a claim to Medicare. I, the Medicare beneficiary or my legal representative understand that a Medicare payment will not be made for any items or services furnished by Carolina Holistic Medicine that would otherwise been covered by Medicare as there was no primate contract and a proper

Medicare claim will not be submitted.

I, the Medicare beneficiary or my legal representative sign this information sheet 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 that I am not compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners who have opted out. I, the Medicare beneficiary or my legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services paid for by Medicare. This information sheet cannot be signed by me, the Medicare beneficiary, or by my legal representative during a time when

I, the Medicare beneficiary, require emergency care services or urgent care services. However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 3044.28 of the Medicare Carriers Manual I, the Medicare beneficiary, or my legal representative will receive or have received a copy (photocopy is permissible) of this information sheet, before items or services are furnished to me. Carolina Holistic Medicine will retain the original contract for the duration of this opt-out period. This contract remains in effect for two years, ending in January of 2017 at which time an additional 2 year opt out renewal will be in effect and when Carolina Holistic Medicine again opts out of Medicare, we will complete a new contract for each Medicare beneficiary and will expediently submit the appropriate affidavit(s) to all local Medicare carriers. Every two years it auto renews. [a separate CMS opt-out may have to be signed at time of visit] (6) Electronic Transmission Disclosure and Acceptance 1. Member(s) understand(s) that the various forms of electronic transmission of information carry with them the unlikely yet possible risk of exposure and potential loss of that information for a variety of reasons. 2. By signing below, Member(s) indicate a desire to do business with Carolina Holistic Medicine (CHM) (Priority Health Healing Ministry) or its affiliated clinics or providers via any or all of these electronic methods of communication, as indicated below: Cell Phone calls & texting (including attached pictures when applicable) Emails (including attached pictures when applicable) Video Conferencing with CHM or their participating clinics or providers 3. By signing this document, Member(s) agree(s) to accept the risks inherent in the use of any of the above indicated communication methods for the purpose of diagnosis, treatment, or any other healthcare or business-related reasons. Member(s) further agree(s) to indemnify and hold harmless CHM and its affiliated clinics or providers in the possible but unlikely event of a breach of confidential or protected

(7) Messages, Email, & information shared with Family members: I acknowledge that it is the policy of Priority Health/ CHM to leave reminder messages on my answering machine, email and/or cell phone text. I also acknowledge that lab reports may be reported directly to me in my follow up appointment and then mailed out (if necessary

Iacknowledge that if I give permission to discuss my health information and plan with a

family member I will provide front desk staff with names of family and contact information and LIMITATIONS to what can or should be discussed (this will be placed in your EHR I acknowledge that this waiver is fully understood in its content. I further attest to reading

and understanding the Cancelation Policy, all opt-out policies and I have read and understand the HIPAA NOTICE OF HEALTHCARE PRIVACY PRACTICES at Priority Health, LLC and Carolina Holistic Medicine. I further attest to understanding our Patient Handbook details and no-show, last minute reschedule or cancellation policy and our non-refundable

Informed Consent on FxMed/Integrative/Alternative & Complementary Treatments:

I will discussed with my physician or provider the use of the recommended protocol based upon the FxMed protocols, FLCCC COVID and Cancer Care and other protocol as modified for use in reducing risk of and/or treatment of COVID-19 or other viral and infectious diseases and syndromes, including the medical controversies surrounding them, potential adverse reactions, side effects and contraindications. I have been able to review these materials on the FLCCC website and make my own choice. I understand there is no guarantee that this will prevent me from becoming infected with or transmitting the SARS- CoV-2 virus and that I need to continue to follow public health measures. We also subscribe to the ILADS protocols for Lyme Disease and tick-borne illness. We also

subscribe to much of IFM/A4M recommendations.

I understand that there is no guarantee as to the outcome of any illness. I agree to assume the risks that could arise, including those which have been explained and which my physician/provider could not have foreseen. I have requested that my physician prescribe /recommend these treatments. I have been adequately informed about the clinical and legal status of this therapy and questions I have asked have been satisfactorily answered. I understand and agree to the financial and other notices that have been provided. I have read and signed the attached sheets for the specific treatments prescribed and/or

PMA: I have been informed and consent to the following Private Membership Associations (PMA) either one or multiple: First Nation Medical Board and the Turtle Healing Band PMA; the Body Healthcare (TBH), and the Priority Health Healing Ministry (PHHM Membership is required in either one or multiple of these PMAs to participate in healing at our centers. "Indigenous medicine is the sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to native cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, assessments, improvement or recommendations of physical and mental conditions including, but not limited to alternative, complementary, holistic, functional and integrative approaches." The practitioners at CHM are Certified Tribal Practitioners (CTPs With FNMB, physicians can be dual licensed for the use of medical alternatives in their practices and protected against state medical boards that oppose them. This is because the Crow Nation has stepped forward to exercise its jurisdiction over the practice of indigenous medicine (see U.S.C., Title 25, Section 1680u), which no other State in the U.S.A. has done. This exercise of Indian jurisdiction provides sovereign immune protection for physicians and others who become licensed as tribal providers and is part of a comprehensive economic development plan for the Crow Nation. Client/members are also afforded certain rights and protections. The Beliefs in a Judeo-Christian ethics and USA Constitutional 1st-Amendment Rights are: That we are here to perform services that when properly integrated will solve age-old problems for the health and vitality of members/clients. That the best model for FNMB/TBH/PHHM is to focus on services that cover a broad range of modalities that will support CTPs in helping members/clients regain and maintain their optimum good health. That as we educate our members/clients regarding nutrition and lifestyle that the result will be to simplify and enhance their lives. In saying "no" to some opportunities if by saying "yes" our focus will be redirected from our core competencies and thus, create a less than optimal member/client experience. In collaboration between provider members with their staff and team members and in being fair and just in our relationships. In striving for long-term relationships where we do right by doing good. In striving for the presence of excellence in everything we do and for the elimination of mediocrity in all of our daily undertakings. Mediocrity has no place in our personal or business lives and we commit to working with each other to eliminate this destructive force. In both the "Golden Rule" (Do unto others as you would have them do unto you) and the and "Platinum" Rule" (Do unto others what they would have you do unto them We will treat other people respectfully and exhibit good manners and courteous behavior to everyone we encounter (incl., CTP members, team members, members/clients, family, suppliers, vendors, or anyone else with whom we interact That wherever we go, and whatever we do, we always represent the First Nation Medical Board, The BODY Healthcare and/or Priority Health Healing Ministry. Therefore, we commit to treating everyone with respect and with a pleasant demeanor. That no one is beneath us.

We acknowledge that everyone makes mistakes. When mistakes occur, we will collaborate with one another and attempt to resolve matters in a courteous and kind manner. In supporting and promoting the PMA Care Programs by doing whatever we can to make positive contributions to it in every reasonable and possible way. That every new day brings fresh and unique opportunities to demonstrate gratitude for the opportunity granted us to change our lives and the lives of others. For this opportunity, we are immensely grateful. These entities are 508c1A tax-exempt (NGOs Practicing in the corporate soul as a common law entity not a statutory law business.

I understand and agree that I am, ultimately, personally responsible for the balance of my account for all professional services rendered. After a mandatory non-refundable deposit to hold my appointment, there is often a balance due after the visit that must be paid at time of service or in advance. I certify the above information is true and correct to the best of my knowledge. | will immediately notify Carolina Holistic Medicine of any changes in my health status or the above information. Please sign Waivers and if applicable CMS-opt-out waivers (sent separately.  If applicable I the resopnsible adult am signing for minor child.