Patient Intake form

Nutritional Informed Consent

According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201 (g) (1), the term “DRUG” is defined to mean: “Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease.”

A vitamin is not a drug. Neither is a Superfood, Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy.

Although a Vitamin, superfood, Mineral, Trace Element, Amino Acid, Herb or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone. Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom.

Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet in order to supply good nutrition supporting the physiological and biochemical processes of the human body.

Insurance Billing

Dr. John Fitzgerald, DC is out of network with all insurance companies. We do not bill your insurance company for you. Before contact your insurance company about anything, please consider the following...

1. If you file a claim with your insurance company, all diagnosis codes and test results will go on file with your insurance company. This can be used to determine future premium costs for you and your family.
2. If your diagnosis includes a hereditary disease like high blood pressure, it will not only be seen on your health records, but also the records for your children and grandchildren and will be used to determine their coverage availability and premium costs.
3. Insurance companies are quick to raise premiums or drop coverage entirely when customers file too many claims, or just one of the wrong kind of claim (like nutritional treatment rather than the medical drug-fix it norm).
4. Your insurance carrier is responsible only for paying benefits covered under your policy and will deny anything they deem “medically unnecessary or experimental”. Nutritional services frequently fall under this category and therefore are not covered which means you are supplying them with diagnosis codes, test results, etc (which they can use against you) yet you see no financial benefit.
5. Rescission – if you have a serious illness, insurance companies will search your file to obtain medical records from the last several years and if they find any inconsistency in your application, your policy is rescinded so they can avoid paying for costly treatments or medication. Any information you share with them could be used against you.
6. Preapproval – if you call your insurance company to find out if certain services are covered, it is a warning sign to your provider that bills are coming which may spark a rescission search on your account.

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

We are very concerned with protecting your privacy. While the law requires that you give us this disclosure, please understand that we have, and always will, respect the privacy of your health information.

There are several circumstances in which we may have to use or disclose your health information.

1. We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.
2. We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services.
3. We may need to use your health information within our practice for quality control or other operational purposes.
4. We may have to disclose your health information to Science Based Nutrition™ to obtain test results and reports.

We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form (§ 164.520). We reserve the right to change our privacy practices as described in that notice. If we make a change to our privacy practices, we will notify you in writing when you come in for treatment or by mail. Please feel free to call us at any time for a copy for our privacy notices.

I authorized Dr.John Fitzgerald to contact me with information related to my personal health needs and interests. The physician's office may use any phone number or email in my personal records to contact me. If contact is made by phone and I am unable to respond, a message may be left with my home answering machine or voice mail service. I may be contacted about the following:

• Appointment reminders or schedule changes.
• Information about alternative treatments, presentations or events
• Other health related information that may be of interest to me

To contact me, I authorize Dr. John Fitzgerald to use and disclose the following information:

• My Name, Address, Email and Phone Numbers
• The Name of my Physician and the Clinic where I was treated

NOTE: NO DIAGNOSIS OR TREATMENT INFORMATION WILL BE USED OR DISCLOSED.

Dr. John Fitzgerald fully supports the protection of health information. Only the physician and office staff will use this information to contact you. While we retain the standard rights of disclosure as provided under HIPAA, this authorization allows us to access only the above authorized information for contact purposes. Dr. John Fitzgerald communicates with patients by emailing forms and test results back and forth. Some of these forms are from DrJohnFitzgerald.com and some are from labs. These forms are also emailed to the patient. The forms are not sent over a special secure server, rather they are sent by regular email. The patient is being made aware of this email method in case they are concerned about their medical information being stolen.

This authorization will remain valid for ten (10) years from the date of signature. You may revoke this authorization at any time or request to receive a copy of the protected health information to be used by writing to Dr. John Fitzgerald, 7355 Bermuda Island St, Las Vegas, NV 89123. In this case, every effort will be made to discontinue future communications.

5. Today's Date
   MM slash DD slash YYYY
6. Signature