Download Informed Consent - AuerFamily Homeopathy, LLC

Informed Consent to Treatment
Welcome to AuerFamily Homeopathy, LLC. This document contains important
information about our professional services and policies. It is now required by Arizona
State Law for such Informed Consent to be signed by all patients. Additionally this form
will serve as a binding agreement between us.
I authorize Carli Auer, Classical Homeopath, and her associates to conduct Homeopathic
assessment and consultation regarding my case. I recognize that the treatment I receive in
this respect is homeopathic and as such no medical diagnosis will be made. Homeopathic
treatment involves the use of homeopathic remedies that are prepared in the manner
described in the Homeopathic Pharmacopoeia of the United States. These remedies are
considered non-toxic and non-habit forming. The goal of Homeopathy is to stimulate the
body’s natural healing process and as such, temporary aggravations of some new and/or
old symptoms may be experienced.
Furthermore, I understand that:
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No claim to cure has been made to me.
The care I receive is to complement and NOT to replace or delay the medical care I
receive from my primary care physician or any other licensed medical practitioner.
I will not consider my conversations with AuerFamily Homeopathy, LLC as medical
advice nor will I use that information to neglect or delay medical care advised by my
primary care physicians.
All matters pertaining to my Rx Prescription Medications is to be handled by my
primary care physician or a licensed medical professional, such as MDs, DOs etc.
The safety and efficacy of alternative therapies has not always been established with
controlled studies to the satisfaction of conventional medicine.
I realize that Carli Auer and her associates will not be providing Hospital or
emergency care for me.
I understand that I (and/or Carli Auer and her associates) have the right to terminate
our professional relationship at any time and for any reason.
I have read the above information in this document and agree to abide by its terms and
conditions.
Patient Name (Please print)
Signature of Patient or Guardian
Date
Fee Schedule:
All initial appointments require a $50 deposit. This deposit is refundable up to one week prior to your first scheduled
appointment.
Initial Comprehensive 2 hour Consultation (Adult = 18+)
Initial Comprehensive 1-2 hour Consultation (2 to 17 yrs of age)
Initial Comprehensive 1-2 hour Consultation (0 to 2 yrs of age)
$250
$200
$175
Acute Care 30-45 minute Consultation (all ages)
$40
Follow-ups 30-45 minutes
Follow-ups 30-45 minutes
Follow-ups 30-45 minutes
$50
$50
$50
Approximate per prescription cost of Homeopathic Remedies are: $19
Follow-up Appointments:
Follow up appointments are scheduled approximately once every 4 to 6 weeks and can take up to 30-45 minutes in length.
It is very important that these appointments are kept, even when you are doing well or continuing to make progress.
Patients who return for their regularly scheduled follow-up appointments complete their homeopathic treatment in shorter
time and with better results. The frequency and potency management of your homeopathic remedy is critical to ensure
proper progress. Research indicates that in cases where the treatment is left incomplete, two things may occur: Initial
symptoms may return or the body may no longer respond to the properly selected remedy, mainly due to either excessive
repetition, or not changing the potency or remedy when needed. Keep in mind that the ultimate goal of homeopathic
treatments is to reach the highest possible level of health and vitality that remains consistent over time.
In order to start and end on time we ask you to arrive 15 minutes prior to your scheduled appointment.
Canceling Appointments:
Less than a 24-hour notice to make changes to your appointment will result in being charged for the appointment.
Please stop taking your remedy if you have missed your follow up appointment by more than 4 weeks.
In other words do not continue your remedy without supervision beyond 4 weeks.
Additionally, if a follow-up appointment is not scheduled within 4 weeks of missed Appointment, your next follow up
appointment will be $100, as it will require more time for us to catch up with your current condition.
Phone Consultations:
Phone calls exceeding 10 minutes are considered consultations and are $40.
We provide Acute Care phone consultation for a fee of $40.
Please note that our Homeopathic Care is only to complement and NOT intended for you to either Avoid or Delay seeking
conventional medical treatment.
In case of emergencies you MUST:
Contact your local primary physician or your local hospital emergency room.
You should know that homeopathic medicines do not interfere with conventional medical treatment.
DO NOT AVOID OR DELAY MEDICAL TREATMENT WHEN NEEDED.
All fees are subject to change without prior notice.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a homeopathic practitioner. In most situations, I
can only release information about your treatment to others if you sign a written Authorization form that meets certain
legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance
consent. Your signature on this Agreement provides consent for those activities, as follows:
I may occasionally find it helpful to consult other health professionals about a case. During a consultation, I make
every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the
information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is
important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my
Notice of Policies and Practices to Protect the Privacy of Your Health Information).
You should be aware that I practice in an office suite along with other health professionals and administrative staff
members. All of the health professionals are bound by the same rules of confidentiality and have been given training
about protecting your privacy and have agreed not to release any information outside of the practice without
permission.
If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact
family members or others who can help provide protection. There are some situations where I am permitted or
required to disclose information without either your consent or Authorization:
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If you are involved in a court proceeding and a request is made for information concerning the professional
services I provided you, such information is protected by the physician-patient privilege law. I cannot provide any
information without your or your legal representative’s written authorization, or a court order. If you are involved
in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely
to order me to disclose information.
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If a government agency is requesting the information for health oversight activities, I may be required to provide
it for them.
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If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in
order to defend myself.
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If a patient files a worker’s compensation claim, and I am providing services related to that claim, I must, upon
appropriate request, provide appropriate reports to the Workers Compensation Commission or the insurer.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to
protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are
unusual in my practice.
 If I have reason to believe that a child under 18 who I have examined is or has been the victim of injury,
sexual abuse, neglect or deprivation of necessary medical treatment, the law requires that I file a report with the
appropriate government agency, usually the Office of Child Protective Services. Once such a report is filed, I may
be required to provide additional information.
 If I have reason to believe that any adult patient who is either vulnerable and/or incapacitated and who has
been the victim of abuse, neglect or financial exploitation, the law requires that I file a report with the appropriate
state official, usually a protective services worker. Once such a report is filed, I may be required to provide
additional information.
 If a patient communicates an explicit threat of imminent serious physical harm to a clearly identified or
identifiable victim, and I believe that the patient has the intent and ability to carry out such threat, I must take
protective actions that may include notifying the potential victim, contacting the police, or seeking hospitalization
for the patient.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my
disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential
problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws
governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required,
formal legal advice may be needed.
PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical
Record. Except in unusual circumstances that involve danger to yourself and/or others or where information has been
supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record if you request it
in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For
this reason, I recommend that you initially review them in my presence. If I refuse your request for access to your
records, you have a right of review, which I will discuss with you upon request.
PATIENT RIGHTS
HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of
protected health information. These rights include requesting that I amend your record; requesting restrictions on
what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of
protected health information that you have neither consented to nor authorized; determining the location to which
protected information disclosures are sent; having any complaints you make about my policies and procedures
recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my
privacy policies and procedures.
MINORS & PARENTS
Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents
to examine their child’s treatment records.
I have read the above information in this document and agree to abide by its terms and conditions.
Patient Name (Please print)
Signature of Patient or Guardian
Date
CONSENT TO VIDEOTAPE
Homeopaths often videotape cases. This is voluntary and consent is optional. We use videotapes for two
purposes:
1) To study the case by carefully observing the patient on video. This can often help in correct remedy
prescription.
2) To use in teaching, as an instructional tool in seminars and lectures on homeopathy. Videotapes of patient’s
office visits are of the most valuable learning tools for homeopathic students as well as master homeopaths to
understand and see the homeopathic process of healing.
Your consent to videotape is optional, but greatly appreciated for the advancement of homeopathic medicine
and education.
Consent #1: I authorize Carli Auer and AuerFamily Homeopathy, LLC to videotape my office visit only for the
purposes of my personal case and the video will not be seen by anyone except Carli Auer or associates of
AuerFamily Homeopathy, LLC.
Printed Name_______________________ Signature ______________________
Date________________
Consent #2: I authorize Carli Auer and AuerFamily Homeopathy, LLC to videotape my office visit and to use
the video for teaching purposes in Homeopathic trainings, lectures, and seminars. I understand that identifying
information such as my name and address will NOT be disclosed to the audience.
Printed Name_______________________ Signature_______________________ Date________________
This consent may be revoked at any time with a signature and date below.
Signature _________________________________
Date ___________