North Seattle Natural Medicine Policy Forms

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Informed Consent for Medical Treatment Policy

I, as a patient, have the right to be informed about my condition and recommended care. This disclosure is to help me become better informed so that I may make the decision to give, or withhold my consent as to whether or not to undergo care, having had the opportunity to discuss the potential benefits, risks, and hazards involved. I hereby request and consent (for myself or for the patient for whom I am legally responsible) to examination and treatment by all practitioners working and training at North Seattle Natural Medicine. I understand that I have the right to ask questions and discuss to my satisfaction with my North Seattle Natural Medicine practitioner: 1) My suspected diagnosis or condition; 2) The nature, purpose and potential benefits of the proposed care; 3) The inherent risks, complications, potential hazards, or side effects of treatments and procedures; 4) The probability or likelihood of success; 5) Reasonable available alternatives to the proposed treatments or procedures; 6) The possible consequences if treatment or advice is not followed and/or nothing is done. I understand that my treatment and evaluation may include, but is not limited to: ● Physical exam (general, musculoskeletal, orthopedic, and neurological assessments); ● Common diagnostic procedures (venipuncture, pap smears, diagnostic imaging, laboratory evaluation of the blood, urine, stool, and saliva); ● Soft tissue and osseous manipulation (massage, neuromuscular technique, muscle energy stretching, cranio-sacral therapy, osseous manipulation of the extremities and spine); ● Allergy skin testing and immunotherapy; ● Electromagnetic and thermal therapies (ultrasound, low and high volt electrical muscle stimulation), transcutaneous electrode stimulation, and infrared or ultraviolet therapies); ● Dietary advice and therapeutic nutrition (use of foods, diets, supplements, and intramuscular injections); ● Herbs/natural medicines (various therapeutic substances including plants, mineral and animal materials. Substances may be prescribed in the forms of teas, creams, pills, powders, tinctures, suppositories, topical creams, pastes, plasters, washes, and other vehicles which may contain alcohol or allergens which it is the patient’s responsibility to monitor); ● Homeopathic remedies (often highly-diluted quantities of natural substances); ● Hydrotherapy (use of hot or cold water, colon hydrotherapy, cryotherapy); ● Over the counter and prescription medications (including only FDA-approved medications). I understand and I am informed that in the practice of naturopathic medicine, there are some risks and benefits involved in evaluation and treatment, including but not limited to: Pain; discomfort; blistering; minor bruising; discoloration; infections; burns; loss of needle insertions; allergic reaction to prescribed substances; soft tissue or bone injury; an aggravation of pre-existing symptoms; and emotional response. Notice to pregnant patients: All patients must alert the provider if they know or suspect that they are pregnant, since some common naturopathic treatments can present a risk to pregnancy. Treatment intended to induce labor requires a letter from a primary care provider providing authorization and recommending such a treatment. Notice to patients with bleeding disorders, pacemakers, and cancer: For your safety, it is important to alert your provider of these conditions. I do not expect North Seattle Natural Medicine’s practitioners to be able to anticipate and/or explain all risks and complications involved in my treatment. I wish to rely on the provider to exercise best judgement during the course of my evaluation and treatment based on the known facts. I understand that it is my responsibility to request that the provider explain therapies and procedures to my satisfaction. I further acknowledge that no guarantees have been made to me concerning the results of my treatment. By signing below, I acknowledge that I have been provided ample opportunity to read this form or that it has been read to me. I understand the above and have given my consent to evaluation and treatment by North Seattle Natural Medicine’s practitioners. I intend for this to act as a consent for my entire course of treatment for both my present condition and any future conditions that may arise.

Payment Policy

Thank you for choosing us as your naturopathic care provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request. 1. Insurance. We participate in most insurance plans. If you are insured by a plan we do business with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you do not have any coverage, we are able to offer a Time of Service discount, however payment must be received on the Date of Service otherwise we have to bill the patient for the full amount. 2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. 3. Non-covered services. Please be aware that some – and perhaps all – of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit. 4. Labs/Imaging/Medical Procedure Costs: If you are intending on using your health insurance for any of these services ahead of time, North Seattle Natural Medicine is not responsible for checking your coverage. The patient must contact their insurance directly in order to inquire about lab/imaging/medical procedure costs, as well as co-insurance and deductibles for these services. North Seattle Natural Medicine has no input, affinity, or influence over these costs. All costs or personnel involved in these services are independent of our clinic. 5. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance cards to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. 6. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract. We are not able to bill out for any supplements, sublingual immunotherapy vaccines, or phone consults/phone appointments, nor are we able to assist your insurance provider with any questions if you attempt to bill these items/services. 7. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. Some insurance companies require the doctor to bill to the insurance within a certain time frame after the appointment, so if you do not provide the office with your updated insurance in time you could wind up responsible for the visit costs. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. 8. Nonpayment. If a bill is not paid in full by 90 days, there will be a fee applied to the bill which will compound every month it is not paid. When your bill is 90 days past due, you will receive a notice by phone and/or mail requesting payment. The fee applied to the unpaid bill is subject to change. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. 9. Missed appointments. Our policy is to charge a cancellation fee for appointments that are missed/cancelled within 24 business hours before the appointment time. These charges will be your responsibility and billed directly to you, even in the event that you do not receive a reminder email or your reminder email contains incorrect information. Please help us to serve you better by keeping your regularly scheduled appointment. The cancellation fee amount is subject to change. Repeated missed appointments may result in termination of care at North Seattle Natural Medicine. Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

Email Disclosure and Consent Policy

North Seattle Natural Medicine offers patients the opportunity to communicate by email. Transmitting patient information poses several risks of which the patient should be aware. The patient should not agree to communicate with North Seattle Natural Medicine via email without understanding and accepting these risks. The risks include, but are not limited to, the following: • The privacy and security of email communication cannot be guaranteed. • Online services and your employer may have a legal right to inspect and keep emails that pass through their systems. • Email can introduce viruses into a computer system, and potentially damage or disrupt the computer. • Email can be forwarded, intercepted, circulated, stored or even changed without the knowledge or permission of North Seattle Natural Medicine or the patient. Email senders can easily misaddress an email, resulting in it being possibly sent to one or more unintended and unknown recipients. • Email is indelible. Even after the sender and recipient have deleted their copies of the email, backup copies may exist on a computer or in cyberspace. • Email can be used as evidence in court. North Seattle Natural Medicine will use reasonable means to protect the security and confidentiality of email information sent and received. However, patients choosing to communicate with North Seattle Natural Medicine via email are understood to have consented to the use of email communication with our clinic despite these risks, and in understanding of acceptance of the following: Emails to or from the patient concerning diagnosis or treatment may be made part of the patient’s medical record. Individuals authorized to access the medical record, such as staff and billing personnel, will have access to those emails. North Seattle Natural Medicine may forward emails internally to North Seattle Natural Medicine staff and to those involved, as necessary, for diagnosis, treatment, reimbursement, healthcare operations, and other handling. North Seattle Natural Medicine will not, however, forward emails to independent third parties without the patient’s prior written consent, except as authorized or required by law. Email communication is not an appropriate substitute for clinical examinations. In the event that you are experiencing symptoms that require the input of a doctor, please call our clinic to schedule an appointment or call medical emergency services. North Seattle Natural Medicine cannot guarantee that your email reaches us in a timely manner or that you receive a response within an expected time frame. The patient is responsible for following up on email sent to North Seattle Natural Medicine and for scheduling appointments where warranted. North Seattle Natural Medicine is not responsible for information loss due to technical failures associated with email software or Internet providers. To communicate by email, the patient shall: • Take reasonable and common sense measures to safeguard email privacy and security such as avoiding use of third party or employer machines and networks, using secure passwords, and other measures deemed appropriate by current best practices for basic email security. • Inform North Seattle Natural Medicine of any changes in the patient’s email address. • Include in the email the category of the communication in the email’s subject line, for routing purposes (e.g., ‘appointment request’); and the name of the patient in the body of the email. • Withdraw consent to communicate confidential information by email only by written communication to North Seattle Natural Medicine. Email/detailed message billing: The doctors are able to bill your health insurance for some email/detailed message based communications. Please note, that the physicians will always have the right to ask for an office visit in lieu of an email. The email content must be brief and not be used to diagnose a new physical ailment. In brief, every 7 days we can bill for up to 20 minutes of physician time used to answer emails. On the 8th day, the email billing cycle will restart. We will be limiting this to no more than 3 email communications between the patient and the physician in a one week time period before we request an office visit. Additionally, at any time the physician may request an office visit if the email content is too complex or needs a physical appointment. If you are a cash/private pay patient that is non insured, the cost for up to 3 email communications in 7 days will be $35. I understand the risks associated with email communication between North Seattle Natural Medicine and myself, and consent to the conditions outlined herein. I understand that North Seattle Natural Medicine does not use encryption software. I consent to be contacted by North Seattle Natural Medicine via email and I understand that I will have the option to opt out of email communications from North Seattle Natural Medicine at any time. I acknowledge North Seattle Natural Medicine’s right to, upon the provision of written notice, withdraw the option of communicating via email. Any questions I may have had have been answered.

These Policy Forms are for the entire clinic of North Seattle Natural medicine, not this specific Doctor.

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