Download Patient Acceptance Policy

IMPORTANT PATIENT
INFORMATION
Patient Acceptance Policy
In order to best serve you, the Patient Acceptance Policy should be carefully reviewed. It is Dr. Beck’s opinion
that you should be well informed on our expectations and clinical procedures. To prevent any misunderstandings
or confusion on what to expect, Dr. Beck would appreciate that you read the below steps and provide your
signature. This will attest to the fact that you have read the Patient Acceptance Policy and understand what is
expected of you.
1. Completion of the following sections:
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Patient Information Form
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The Health History Questionnaire
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The Nutritional Assessment Questionnaire
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Lifestyle Questionnaire
2. It is VERY important for you to carefully and thoroughly complete all of these forms and questionnaires
prior to your first consultation with Dr. Beck. Once Dr. Beck has received your completed forms, our office
will schedule your first consultation. This appointment can be scheduled virtually via Skype, internet webcam
or telephone conference, or in person (at the office).
These questionnaires were developed to gather important information about your lifestyle, eating habits and
mindset. It will help Dr. Beck assist in helping you. The these questionnaires will allow Dr. Beck to correctly
“pinpoint” the most probable cause(s) of your health problems.
3. Medical Records from all physicians since you were first diagnosed with your health condition(s) MUST be
obtained PRIOR to receiving any written comprehensive evaluation and recommendations.
4. Once Dr. Beck has your completed questionnaires and copies of all your medical records, a one-hour
appointment will be scheduled to review your case. The cost for the one-hour appointment as well as Dr.
Beck’s time for reviewing your medical questionnaire, medical records, setting up your case file and
authoring a written report can be found under the consultation tab at dranthonygbeck.com .
5. Based on your scheduled appointment and review of all your medical information, it may be necessary to
obtain an up-to-date Comprehensive Blood Chemistry. The blood chemistry test will include but may not be
limited to:
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Comprehensive Metabolic Panel, which includes 24 important disease markers such as SGOT, SGPT,
GGT, Bilirubin (Liver), BUN, Creatinine, Uric (Kidney), Alkaline Phosphatase (Bone)
Cardiovascular Panel: Cholesterol, Triglycerides, LDL, HDL, Cholesterol/HDL Ratio, LDL/HDL
Ratio, Homocysteine, Fibrinogen
Thyroid Panel: Total T3, Total T4, Free T3, Free T4, TSH, TPO
CBC differential: White Blood Cells and Red Blood Cells, Platelets
Inflammatory markers: Sedimentation Rate, High Sensitivity CRP
Additional labs: Magnesium, 25 OH Vitamin D, Hemoglobin A1C, Glucose, Ferritin
6. Based on your medical history, questionnaire, medical records and initial consultation, it may be necessary to
order additional medical laboratory tests. You will be presented with detailed information on the specific
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tests recommended. The cost payment options for your initial Laboratory tests will be discussed at that time.
Payment can be made via credit card through the website, https://dranthonygbeck.com .
7. If you have not had a physical examination within the last year or since the start of your most recent health
problem, it is required to either schedule an appointment with your primary physician within a reasonable
time after starting with the consultation process.
8. The results of your lab tests may take up to approximately three weeks, at which point, you will be able
scheduled for an appointment to review the findings. This appointment usually takes approximately a 20 to 30
minutes per laboratory test depending on the types of additional lab to review. You will be presented with a
copy detailing the results of your tests, the possible causes of your health problem and the recommended
treatment protocols. It is recommended that you have your spouse or a supportive family member attend this
appointment. The fee for this Review of Findings appointment can be found under the consultation tab at
dranthonygbeck.com . This appointment can be scheduled virtually via Skype, internet webcam or telephone
conference, or in person (at the office).
9. Your treatment may consist of dietary and lifestyle changes as well as prescribed Nutraceuticals, which may
be purchased at the time of appointment or if consultation is virtual in nature, these can be shipped directly to
you.
10. It is strongly recommended that you have access to a computer with a reliable Internet Connection. A Medical
Progress Questionnaire will be sent to your e-mail prior to subsequently scheduled appointments. Completion
of the progress questionnaire is required to monitor your progress. Correspondence by e-mail is strongly
encouraged and is Free of Charge. If you do not have access to the internet, then a copy of the progress
questionnaire can be faxed. If you would prefer to schedule an appointment to discuss any questions, you may
do so.
11. Follow-up consultations may be scheduled every 3, 6 or 12 weeks, allowing you the opportunity to discuss
your progress and any concerns with Dr. Beck. At that time, Dr. Beck can determine what direction to take to
help you continue your progress. Your cooperation in taking “personal responsibility” in your health care
will go a long way in getting better. Consultations can be conducted either by phone, internet conferencing
(Skype or Google Hangout), or in person (at the office). The fee for follow-up consultations is can be found
under the consultation tab at dranthonygbeck.com
12. Abnormal laboratory tests will need to be re-evaluated. The success of your treatment will not only be
measured on the reduction of elimination of your physical symptoms, but on abnormal laboratory tests
returning to a normal status.
I, ________________________________have read and fully understand the Patient Acceptance Policy.
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Patient Signature
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Date
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AUTHORIZATION OF TREATMENT:
I, _________________________________________________, hereby authorize health and nutritional consultations for
myself or my minor child by Dr. Anthony G Beck, and/or physicians, medical assistants and staff here forward referred to as
(AGB).
NOTICE AS TO NATURE OF SERVICES: I seek the medical and health care consultation services of (AGB) employees
and staff. I understand that (AGB) uses some diagnostic and treatment methods that some may be considered holistic,
complementary or alternative. Some of these methods have not been accepted by “mainstream” medicine. I understand that
the principles of this practice are based on Functional Medicine, a health system, in which we believe that the body has an
inherent ability to heal itself given the right tools. Treatment modalities provided by (AGB) are based on functional and
science-based evidence.
Some of the characteristic qualities of therapies that are used by (AGB) include the following:
1. A person’s lifestyle including his or her diet, exercise patterns, sleep habits and stresses are believed to be directly related
to the development and maintenance of illness. (AGB) will evaluate these factors and seek to help the patient give up
negative life style patterns and establish more positive ones regardless of age or type of medical problem.
2. Although prescription and over-the-counter medications are used when a physician believes it is necessary, an attempt is
first made to use products that are natural to the body. These include but are not limited to, nutritional supplements such as
vitamins, minerals, enzymes, amino acids, essential fatty acids and herbs.
3. In addition to recommending that a patient take nutritional supplements by mouth, it is sometimes recommend that a
patient receive a series of injections either intravenously or by intramuscular injection. Some of the reasons for
recommending this procedure include the assurance that the particular substance gets into the body (which may not happen
when the supplement is taken orally and the patient has absorption problems), and achieving high concentration of the
substances in the bloodstream, which may be difficult if the substance is taken by mouth.
4. For some patients, we recommend homeopathy, based on appropriate history. It is based on the principle of “like cures
like,” and uses extremely tiny concentrations of animal, vegetable or mineral substances to stimulate the body’s healing
mechanisms. Although homeopathy is fairly well established in some European countries, India and other countries
worldwide, it is generally not at all accepted by consensus mainstream medicine in the United States, yet is regulated and
authorized by the Food and Drug Administration.
5. Because (AGB) looks for imbalances in the body and for trends that may result in illness if not addressed, tests are
sometimes ordered that may be considered by consensus mainstream medicine to be either unnecessary or of no value. These
may include tests for nutritional status, such as blood levels of vitamins and minerals, hormone levels, test for heavy metals
or tests for allergies.
6. (AGB) feels that environmental factors may play a major role in health and disease. Some of the diseases of unknown
cause maybe triggered or perpetuated by common environmental substances, many of which are man-made. Individuals may
vary greatly in their susceptibility to various substances, so that one individual may be made deathly ill by an exposure to a
substance while another is not at all affected. (AGB) will attempt to identify offending substances and help patients to
detoxify from past exposures that are affecting them.
7. (AGB) very much believes in persons being involved in their own health care and encourage questions, exploration and
participation in decisions surrounding diagnostic and treatment procedures. Consultations are encouraged with consensus
mainstream medicine practitioners and use of any other means that a person feels they need to help them decide about health
issues.
8. Exercise is extremely important in maintaining health and promoting wellness as well as helping one to recover from an
illness. Graded exercise, both aerobic and stretching, is encouraged for most patients.
9. Sometimes medications are used that are approved by the FDA to treat one condition; however, that same medication may
be used for treatment that has not been FDA approved. Perhaps the best example is the use of EDTA chelation therapy to
treat all forms of atherosclerotic cardiovascular disease and other degenerative diseases.
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NOTICE THAT SERVICES ARE NOT PRIMARY CARE: I understand that no physician or any other practitioner that I
see at (AGB) is acting as my primary care physician. As such, emergency services are not offered. I understand that even
though my physician(s) and (AGB) may address issues affecting my general health, the practice is focused on a
complementary, holistic approach to health care and it is in my best interest to have a primary care physician to ensure that I
am fully appraised of all available conventional means to address any medical conditions that I may have.
This is also important because these practices are exclusively office-based and are not affiliated with a hospital. If I become
so ill that I require hospitalization, it is vital that I have a primary care physician with hospital admitting privileges familiar
with my health problems and history. I understand that in addition to a primary care physician, it may be in my best interest
to have appropriate specialists, such as a cardiologist if I have cardiac problems or a pediatrician if I am seeking treatment for
my children.
I also understand that it is my responsibility to inform (AGB) of who my primary care physician and specialists are, to let my
physician know of any diagnoses I have received, and of any treatments I have had or am now undergoing for current
conditions, and that I should keep my physicians and any practitioners I see informed on an ongoing basis. I also understand
that it is very important to let my primary care physician know about any treatments performed by (AGB) in order to
properly and safely coordinate my care.
NO GUARANTEES: I understand that (AGB) does not make any representations, claims or guarantees that I will be helped
with my medical problems or conditions by undergoing treatment at (AGB). However, (AGB) will do the best to help me
accomplish my healthcare and wellness goals.
REVOCATION OF AUTHORIZATIONS: These authorizations will remain active unless revoked by me in writing at
any time. Such revocation will not affect my financial responsibility to pay for services rendered.
NUTRITIONAL SUPPLEMENTS: I understand that (AGB) makes nutritional supplements and other recommended
products available. Many of these products are not available through retail outlets. These are provided for the convenience
of patients. I am in no way obligated to purchase these products from this (AGB). I am free to purchase any recommended
supplements or other products from any source that I choose.
NOTICE TO MEDICARE PATIENTS: (AGB) have opted entirely out of the Medicare program, which means that
Medicare will not cover any services or procedures performed at (AGB). I understand that I will not be able to submit any
claims to Medicare and that if I have a secondary insurance carrier that carrier may or may not choose to reimburse claims. I
understand that I will need to sign a contract (Medicare Private Contract Agreement) agreeing not to submit to Medicare, that
Medicare limiting fees do not apply, and that I will be personally financially responsible for any services received. I
understand that Medicare will not be reviewing any claims, and that an opinion by Medicare that a service is not medically
necessary in their view of care would not discharge my responsibility for payment of said service(s).
INSURANCE CLAIM MANAGEMENT: (AGB) does encourage patients to seek reimbursement of any applicable
insurance claims that may apply. However, (AGB) does not participate nor is contracted with any insurance company. A
receipt and an encounter form will be provided to me if requested at the time of visit to submit to my insurance company on
my own. (AGB) does not prepare or submit insurance claim forms. (AGB) is not obligated to respond to insurance carrier
requests for information, and is not be obligated to take action on my behalf against an insurance carrier for collecting or
negotiating my insurance claim.
I understand I may be charged for responding to requests for information. (AGB) does not typically send information directly
to insurance carriers. I am responsible for the payment of services provided by (AGB) in full at the time of service without
regard to insurance coverage. I am entitled to know the cost of all services and procedures in advance and I will ask if they
are not told to me.
FINANCIAL INSURANCE RESPONSIBILITY FOR ALL SERVICES: I understand and agree to the following policies
regarding financial and insurance responsibilities. Payment is required in full at each visit; (AGB) does not accept
assignment. I am responsible for charges incurred for all treatment rendered. Differences between integrative and
conventional medicine can lead to differences in views about medical necessity. I agree that I am responsible for any
payments for services my insurance carrier determines, either now or at a later date, to be unreasonable or not medically
necessary. This includes, but is not limited to, consultation fees and laboratory tests.
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I understand my responsibility to pay includes fees for laboratory and/or other clinical diagnostic testing and/or services
requested by my (AGB). I also agree to be responsible for costs and expenses, including court costs, attorney fees and
interest, should it be necessary for (AGB) to take action to secure payment of an outstanding balance owed. Charges are
based on time spent in consultation with the (AGB) and appropriate services rendered.
Full payment is expected at the time of services rendered. Any and all past due patient balances, if applicable, will be
collected before my appointment. In addition to the fee for the office visit, the cost for lab work or other specialized testing
deemed appropriate to my case will be applied to my balance.
Questions are always welcome. Most of the labs and testing done at the (AGB) are more specialized. The discussion of these
labs and test results are usually in-depth and lengthy. Therefore a review of findings appointment is always scheduled.
Consultations can be conducted either by phone, internet conferencing (Skype or Google Hangout), or in person (at the
office).
(AGB) is committed to providing the best treatment for patients. All appointments are considered confirmed at the time they
are made. At the time my consultation is scheduled I will prepay to make the appointment which will be credited toward the
cost of my consultation. I may receive one courtesy call as a reminder of the appointment. Because a substantial amount of
time has been set-aside for me, I will forfeit any charges for a missed appointment. I understand that I need to contact (AGB)
via the website, https://dranthonygbeck.com 48 hours in advance if I cannot keep the appointment in order to avoid forfeiture
of any and all applicable fees.
PATIENT ACKNOWLEDGEMENT: I certify that the information I provide to (AGB) and my insurance company will be
correct. I certify that I am here to receive consultation services and/or they are not substitution for appropriate medical care.
I do not represent any third party. I have read, understood and agree to the foregoing. I understand that I have the right to
review this consent with an attorney if I choose before accepting any consultation or services from (AGB). I have executed
this consent freely and willingly understand its provisions. I recognize that (AGB) will rely upon my signing of this
document in accepting me as a patient. I acknowledge receipt of a copy of this consent if I have requested it.
I do hereby acknowledge that by signing this statement of understanding that I acknowledge and understand that some, and
perhaps all, of the consulting, medical, preventative, nutritional, and diagnostic consultation provided by (AGB) on or after
the date of my signing this statement may be innovative, non-traditional or unconventional. I further acknowledge that due to
the nature of services that (AGB) offer may not be licensed or regulated in the State which I reside and these services are
offered solely as consultations and recommendations and I have been advised to such fact. (Definition: services that are not
necessarily recognized by traditional medicine, some physicians, some 3rd party purveyors of the AMA, as acceptable
testing/evaluation techniques and/or medical and nutritional recommendations or therapies). I also understand that these
unconventional services may be viewed by 3rd party insurance purveyors as non-covered services, in that they might be
considered unreasonable or unnecessary under any medical insurance program. I also realize that my insurance coverage
may not pay for such uncovered services and that I will be personally responsible for payment to (AGB). I understand that I
will pay all costs including reasonable attorney fees, should that become necessary. I understand that all outstanding
balances bear interest at the maximum rate allowed by law.
I understand that my signature represents full informed consent for any and all treatments, services, and recommendations
offered and given to me or my minor child at (AGB) and that I will not be required to sign individually separate consent
forms for any treatments received at (AGB).
Signature of Patient or Responsible Party: ___________________________________________________________
Patient Name: ______________________________________________________________
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