Subject: Confirmation of Consulting Agreement Between Consultant and you the ”Client”.
To Whom It May Concern:
I. Introduction
Thank you for considering retaining me, Marisa Houser, ND & LAc, to serve you as a
health and wellness consultant (“Consultant”).
I have dedicated my career to helping individuals achieve optimal health. In the
context of a consulting relationship, I can learn more about your lifestyle, living
environment, and overall well-being. This will enable me to work with you to explore
personalized plans with the objective of aiding your efforts to enhance the quality of
your life and well-being.
Although I am licensed to practice as a naturopathic doctor in Connecticut, I am not licensed to practice as a naturopathic doctor in state out side of Connecticut, the state in which you reside. In addition, I hold no clinical or professional license or registration of any type in state out side of Connecticut. For that reason, if we are to proceed with this consulting arrangement, it is important that we understand and agree on the limitations, terms and conditions of the Consultant–Client relationship as set forth in this Consulting Agreement (“Agreement”).
II. My Role as Consultant and My Disclaimer of Provision of Any Services
Requiring Licensure
This Agreement is intended to make clear that I am providing to you only consulting
services that require no state licensure or registration in your state. In my role as
Consultant, I cannot, and, therefore, I will not, provide any healthcare, medical,
nutritional or other services that are required by law to be provided only by licensed
physicians, naturopathic doctors, or other licensed clinicians or professionals in your state. Accordingly, I will not provide you with any diagnosis of any health condition; nor will I provide any services that constitute treatment or efforts to prevent or cure any physical, mental, or emotional issues. Our consultations will involve my offering non-medical information for your consideration only, and my services are not intended to be a substitute for any medical or professional advice, diagnosis, or treatment. If you do not agree to this limitation on my services, you should look to a healthcare provider or other professional that is properly licensed in your state. In addition, during our consulting relationship, I may suggest that you seek out a licensed healthcare provider if I believe it appropriate under the circumstances, and you, of course, are free to seek such licensed services at any time, on your own, regardless of this Agreement.
III. Compensation and Other Terms and Conditions
Consistent with my role as Consultant, I am not credentialed with any insurer of any
type for the consulting services I provide. Compensation for my consulting services
is charged directly to you as the responsible party. I do not maintain or supply any
medical record documentation; nor do I use, refer to, or supply Current Procedural
Terminology (“CPT”) codes in connection with my consulting services.
You are free to terminate this Consulting Agreement at any time for any reason; and
I have the same right to terminate this Agreement for any reason at any time.
I cannot guarantee any outcomes or results for you. This remains true even if you
take actions or implement strategies arising from my comments, suggestions or our
discussions during our consultations. You are solely responsible for your own
healthcare decisions.
I will take reasonable steps to keep confidential any information shared by you with me, whether oral or documented, except to the extent I am required to make
disclosures as required by law. Please understand that this Agreement, our
consulting relationship, and any information shared by either of us during the term of
this Agreement are not protected under law as privileged communications; nor are
they protected under the Health Insurance Portability & Accountability Act (“HIPAA”)
or other statutory or regulatory privacy or confidentiality protection.
This Agreement embodies all the terms and conditions of this Agreement; the
entirety of our Agreement is contained in this document.
IV. Signature to Acknowledge Understanding and Agreement
I look forward to the opportunity to work with you. The signature below indicate
that you have read this Agreement, understand its content, and agree to its terms and conditions.