(BE SURE TO READ WHOLESOME HEALTH'S POLICY DOCUMENT ATTACHED. MORE DETAILED INFORMATION ABOUT PROCEDURES/COVERAGE & BILLING IS DISCUSSED ON THE FOLLOWING PAGES.)
AUTHORIZATION FOR TREATMENT: I consent to examination, treatment and any procedures including emergency treatment deemed necessary and ordered by our physician/providers and I am personally responsible for any charges. AUTHORIZATION FOR INSURANCE: I authorize release
of any information concerning myself, or child, to my insurance company regarding treatment for services rendered. AUTHORIZATION FOR
INSURANCE BENEFITS: I authorize my insurance company to send payment directly to Wholesome Health, LLC for services covered by the
insurance plan. AUTHORIZATION OF RECEIPT OF PRIVACY NOTICE/PRACTICE POLICY INFORMATION: I hereby acknowledge that Wholesome Health, LLC has provided me a copy of their Privacy Notice/Practice Policy information. AUTHORIZATION TO CONTACT ME: I authorize Wholesome Health, LLC to contact me by phone electronic mail or US mail to provide a reminder of appointment, gather demographic or insurance information, or to inform me of services or events offered at the facility. I have read Wholesome Health, LLC's Practice Policies information.
I authorize Wholesome Health to send lab results and other personal information to the above email account. I understand this information may
contain my date of birth.
PATIENT FINANCIAL POLICY
OUR POLICY requires payment at the time of service. If you are a member of a HMO, POS or PPO plan
who has chosen us as your provider of care, it is your responsibility to:
• Provide us with the information required in filing a claim: the insurance card, patient ID number
employer, date of birth, address and social security number. The above information is requested on
the Patient Registration form, completed during the initial or subsequent visit.
• Pay your deductible, co-payment, or total balance at time of service, if applicable. Failure to do so
can and will result in a $50.00 surcharge to your account.
• Make sure we have a current referral form on file if required by your insurance plan. If we do not
have a referral on file at the time of your visit, your insurance company may hold you responsible for
all charges. You may also be sent back to your Primary Cary Physician prior to begin treated in
order to obtain a referral authorization.
It is our responsibility to:
• Submit a claim to the insurance carrier provided
• Provide the insurance carrier with the necessary information, to determine the medical and surgical
If your insurance carrier has not chosen Wholesome Health, LLC as one of their participating providers,
• Require payment at the time of service
• Assist the patient in submitting the proper documentation so that they can file the claim: detailed
statement summary, proper ICD-9 and CPT codes
• We gladly accept cash and personal checks with proper identification. (Please note: A $25.00
overdraft charge will be added to all returned checks).
Missed appointments: you may be charged a no-show fee of $50.00 for a missed appointment.
When you bill remains unpaid, a collection agency may be chosen to manage delinquent accounts. If your
account is placed with a collections agency, the patient will be charged a 30% surcharge. The patient is
solely responsible for all costs of collections.
Thank you for choosing Wholesome Health, LLC for your entire healthcare needs!
I have read and fully understand my financial responsibilities under this policy.
WAIVER OF LIABILITY FOR NON-COVERED SERVICES
Dear Managed-Care Beneficiary:
The managed-care contractor with whom you have been insured (e.g. HMOs, PPOs, etc.) many do not cover some services provided at Wholesome Health, LLC. Each insurance carrier has certain criteria on which they base payment decisions. Dr. Owen will do her best to anticipate what services will not be covered, but each company has different rules & policies about such things. By signing this waiver, you are
agreeing to pay Wholesome Health, LLC, directly for any charges not covered by your insurance
I understand that my insurance carrier may not pay for some services. I understand that it is my responsibility to contact my insurance company to determine if coverage is available. If coverage is not available and I choose to obtain the service, I agree to pay personally for the service(s).
PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
• I hereby give my consent for Wholesome Health, LLC, to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).
• The Notice of Privacy Practices provided by Whole Family Medicine, LLC, describes such uses and disclosures more completely
I have the right to review the Notice of Privacy Practices prior to signing this consent. Wholesome Health, LLC, reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be
obtained by forwarding a written request to Wholesome Health, LLC.
With this consent, Wholesome Health, LLC, may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment
reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among other.
With this consent, Wholesome Health, LLC, may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient health records.
With this consent, Wholesome Health, LLC, may e-mail to my home or other alternative location any items that
assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right
to request that Wholesome Health, LLC, restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Wholesome Health, LLC, to sue and disclose my PHI to carry outTPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Wholesome Health, LLC, may decline to
provide treatment me.
INFORMED CONSENT TO ROUTINE PROCEDURES/TREATMENTS
** DO NOT SIGN THIS FORM WITHOUT READING/UNDERSTANDING ITS CONTENTS**
I understand that Physicians rendering the services at Wholesome Health, LLC, are owners, employees or independent professionals engaged in the private practice of medicine.
1. I acknowledge and understand that during the course of my/my child’s care and treatment, it is likely that various types of routine diagnostic and treatment procedures (“Procedures”) may be utilized, which are considered necessary techniques for the ordinary care and treatment of condition(s).
2. While these types of Procedures are routinely performed in hospitals and doctors’ offices without incident,there are certain risks associated with each of these Procedures.
3. The physician or his/her associates or assistants are responsible for providing me with information about the Procedures and for answering all of my questions. It is not possible to enumerate each and every risk for
every Procedure utilized in modern health care. However, physicians who practice medicine at Wholesome Health, LLC, have attempted to identify the most common Procedures, their associated risks and possible alternatives. If I have further questions or concerns regarding these Procedures, I agree to ask my/my child’s
physician to provide additional information.
The Procedures referenced herein may include, but are not limited to, the following:
a) Needle sticks, such as shots, injections or intravenous injections (IV’s). The risks associated with these types
of Procedures include, but are not limited to, nerve damage, causing tingling or burning, infection, swelling, bruising, infiltration (fluid leakage into surrounding tissue), skin sloughing, bleeding, clotting, allergic reactions
or paralysis. Alternatives to Needle Sticks (if available) include oral, rectal, nasal or topical medications (each of which may be less effective) or refusal of treatment.
b) Physical test and treatments, such as vital signs, internal body examinations, wound cleansing, wound dressing, range of motion checks, rehabilitation procedures, etc. which may be utilized in conjunction with diagnosis
and treatment. The risks associated with these types of Procedure include, but are not limited to, reactions to the material(s) used, infection, bleeding, discomfort, muscular-skeletal or internal injuries, nerve damage, paralysis, bruising, worsening of the condition and/or refusal of treatment, no practical alternatives exist.
c) Medications/drug therapy, which may be utilized in the care and treatment of patients. The risks associated with these types of Procedures include, but are not limited to, food-drug-herbal interactions, allergic
reactions, adverse reactions, drug dependency and both long and short-term side effects, which vary from medication to medication. Apart from varying the medication prescribed and/or refusal of treatment, no practical alternatives exist.
FUNCTIONAL MEDICINE LABORATORY TESTING INFORMED CONSENT
The purpose of functional medicine laboratory testing in our office is to evaluate nutritional, biochemical or
physiological imbalance and to determine any need for medical referral. These lab tests in our office are not intended
to diagnose disease. This office utilizes conventional lab tests as well as functional medicine assessment.
Functional medicine assessment is designed to assist our doctors and other healthcare providers in finding the
underlying causes of your condition. Functional medicine has evolved through the efforts of scientists and clinicians
from the fields of clinical nutrition, molecular biology, biochemistry, physiology, conventional medicine and a wide
array of scientific disciplines. Functional medicine evaluates the body as a whole, with special attention to the
relationship of one body system to another and the nutrient imbalances and toxic overload that may adversely affect
Your medical physician may or may not agree with the necessity for – or our interpretation of – these tests. Please
discuss any questions or concerns with our doctors.
I have read and understand the above: