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  • CMS (Medicare) Opt Out Waiver
  • Cancellation Policy/ Payment / Insurance  
  • Records and Rx information
  • HIPAA forms
  • General Medical Waiver
  • Text & E-mail Notification Waiver
  • Medicare/CMS Opt Out (required for all those on Medicare)

 

 

  • General Medical Waiver
  • Cancellation Policy/ Payment / Insurance
  • Records and Rx information
  • HIPAA
  • Medicare/ CMS Opt Out
  • Texting/email allowance waiver

​I understand that by visiting and consulting with CHM, Dr. Saleeby and all contracted Advanced Providers (NP/PA) that we are practicing the new paradigm in medicine under what can be described Integrative or Functional Medicine.  This means we subscribe to a higher Evidence Based Medicine paradigm than what is currently considered standard care Allopathic mainstream Western Medicine.  Therefore we may not limit ourselves to current Practice Guidelines and may implement more advanced and current practices (some may consider "experimental" in mainstream medicine).  By signing this waiver I fully understand and agree to proceed.

(1) Office visits / Payment / Membership (Care Plans) / Insurance / Records and Rx information (please review all sections; by signing you acknowledge you have read and understand these forms.)

Office Visit | Especially for your first office visit, arrive 20-minutes before your
designated appointment to complete check-in process. We try to adhere to a no-wait policy, so if you are late it will delay others and your visit will be adjusted in duration or you will be rescheduled. Visit time is dependent on your chief complaint(s) or reasons for visit, they will be scheduled appropriately.

No-Show Policy | Appointments must be canceled at least 72 business hours prior to the scheduled appointment time for existing paitents (new patients forfeit their deposits). No-shows are unacceptable.  After 72 business hours you will be charged a fee or forfeit your deposit.  Repeated N/S or cancellations can result in dismissal from practice.

There is a $100 no-show charge and appointments will not be rescheduled until that is paid in full.  If on a PLAN a visit will be used in place of a deposit or fee.  Repeated no-shows will result in a termination of the provider/patient relationship.  The $ deposit will be collected at time of appointment to secure and hold your block of time with provider(s). (Not applicable with some membership plans) ALL new patients are required to pay a $100 or $200 deposit to hold an appointment.  That will be forfeited if you do not adhere to our policy.  This is a non-refundable deposit.


Payment | Payment is due at the time service is rendered. We accept cash, checks, money orders, and most major credit cards. Checks are payable to Priority Health, LLC or Carolina Holistic Medicine. Unresolved or delinquent balances may be placed with an outside collection agency and may also be subject to finance charges, attorney fees, and collection agency fees.  If you are due to be on membership you have until the end of that business day to sign up or face the Fee-for-Service fees associated with that visit.  As a membership practice you may be better served to be on one of our care plans.  It is optional but does provide some additional benefits not seen with Fee-For-Service.

As of January 1st, 2015, we no longer file health insurance claims, we are a direct pay practice and will provide you documentation to help you file for reimbursement through your insurance company (excluding Medicare as that is not allowed). Patients on membership care plans cannot submit for insurance reimbursement, however costs may be reimbursable through some HSA plans. (Patients will need to confirm eligibility through their individual plans).  We can prorate quarterly your membership fees on a SuperBill.


Insurance | Please bring your photo ID (e.g. Driver's License) and your current insurance ID card to each visit. We will provide this information to 3rd party vendors who do file insurance claims.  Make sure you update us if these change.

We currently are OUT-OF-NETWORK providers with all insurance carriers. This also included Medicare (CMS) and Medicaid.

Insurance info is important for Lab processing.  Medication Plan info is important so if you have it please provide us.


Bring all your medications and non-prescription remedies (supplements) in their original bottles (or printed out on paper) with you to your first appointment so we can accurately review your regimen.  This will help our nurse keep an accurate Medication List for you in our Electronic Health Record. You also must note the name of the physician(s) who prescribed each medication if not by us.  If you do not have this list, your appointment may be rescheduled.

We will not renew or refill prescriptions by phone unless you are on a PLAN.  During each office visit, be prepared to tell the provider what you need to ensure that your medications refills do not lapse. Refill requests should be submitted to our offices by your pharmacy. Our prescription nurse will address all emails, faxes or E-Requests for refills sent from the pharmacy. Please do not call. The email for specialty refills is rx@carolinaholisticmedicine.com, this Inbox is monitored twice per day (Monday-Thursday by 4PM) and all requests are presented to providers for approval. Refills may take 48-72 hrs during business days to process. 

Note that neither scheduled drugs (opiates, benzos) nor antibiotics are routinely called in to the pharmacy without an office visit or telehealth visit. We do not refill Rx after Thursday afternoon after 4PM until next working day (Monday).  We also have a new Opioid/Scheduled Drug policy that limits the Rx of these classes of drugs.

Lab Results and Other Results | All test results are reviewed by each ordering provider (and overseen by Dr. Saleeby) before they are signed-off on & filed. If any significant findings are noted, you will be contacted. We ask that you DO NOT call us for results. Likewise, DO NOT ask us to explain the results by phone, email or by fax. Such matters will only be addressed at scheduled office or telehealth appointments.  Please review our Patient Handbook for further details.

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(2) NOTICE OF HEALTHCARE PRIVACY PRACTICES AT PRIORITY HEALTH, LLC

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully.

We Have a Legal Duty to Safeguard Your Protected Health Information (PHI):
We are legally required to protect the privacy of health information that may reveal your identity. This information is commonly referred to as protected health information, or PHI for short. It includes information that can be used to identify you that we have created or received about your past, present or future health or condition, the provision of health care to you, or the payment of this health care. We must provide you with this notice about our privacy practices that explains how, when and why we use and disclose your PHI.


With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. We are legally required to follow the privacy practices that are described in this notice.
We reserve the right to change the terms of this notice and our privacy policies at any time. Any changes will apply to the PHI we already have. Before we make an important change to our policies, we will promptly change this notice and post a new notice. You can also request a copy of this notice at any time from our office/practice manager by calling our office.


How We May Use and Disclose Your Protected Health Information:
We use and disclose health information for many different reasons. For some of these uses or disclosures, we need your prior consent or specific authorization. Below we describe the different categories of our uses and disclosures and give you some examples of each category.
During your intake, prior to receiving any health care services, you will be asked to sign a statement permitting Priority HEALTH (dba Carolina Holistic Medicine) and its medical staff to release your health information for purposes of Treatment, Payment and Health Care Operations. A description of each of these uses is described as follows.
Uses and Disclosures Relating to Treatment, Payment or Health Care Operations.
We may use and disclose your PHI for the following reasons:
For treatment. We may disclose your PHI to physicians, nurses, medical students, and other health care personnel who provide you with health care services or are involved in your care.


We may use and disclose your PHI in order for you to collect payment for the treatment and services provided to you. For example, we may provide portions of your PHI to our billing department and your health plan to get your claims processed for the health care services we provided to you. We may also provide your PHI to our business associates, such as billing companies, claims processing companies and others that process our health care claims or provide services on our behalf, or provide services directly to you.
For health care operations. We may disclose your PHI in order to operate our health care delivery system. For example, we may use your PHI in order to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided health care services to you. We may also provide your PHI to our accountants, attorneys, consultants and other in order to make sure were complying with the laws that affect us.
To the extent we are required to disclose your PHI to contractors, agents and other business associates who need the information in order to assist us with obtaining payment or carrying out our business operations, we will have a written contract to ensure that our business associate also protects the privacy of your PHI.

More information is available at:

https://www.hhs.gov/hipaa/for-individuals/index.html

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(3) Advance Beneficiary Notice of Non-coverage (ABN)

This no longer applies as we are OUT OF NETWORK with all Health Insurance programs INCLUDING Medicare.

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(4) Waiver


I the undersigned or Representative, do agree and consent to all medical treatments and services provided by Dr. Yusuf (JP) Saleeby, MD, his staff and practitioners at Priority Health, LLC, DBA Carolina Holistic Medicine (CHM). Medical services are defined as any and all diagnostics and treatments. Providers on our team may include Roxanne Altman, FNP; Adrienne Cohen, DNP; Jennifer Fabrizi, PA; Peter Rambo, AGNP;  Sybil Suriyaniel, FNP; and others.

This includes but is not limited to exercise programs, medicinal treatments, herbals, medical foods, pharmaceuticals, and alternative therapies, drug therapy, IV infusion therapy. I further understand that Dr. Saleeby and Priority Health & CHM do not offer Emergency services and the practice deals with specialized diagnostics and protocols. If an emergency care need arises, I realize I must go to the nearest emergency medical facility (ER) or call 9-1-1 for treatment of life or limb threatening situations. We are a supergeneralist practice in Functional Medicine.

I agree to hold harmless and indemnify Dr. Saleeby, the staff and professionals at Priority Health & CHM from any and all claims involving the medical services provided. I further understand that Dr. Saleeby and the providers do not guarantee results and results of therapy vary from patient to patient. I understand that successful treatment with Dr. Saleeby’s and staff recommendations is primarily based on my own decisions and life choices and compliance /adherence to the plan /program.  I further understand that the practice offers Alternatives to conventional medicine often referred to a complimentary medicine, CAM, Integrative, Functional Medicine and by other names such as natural or organic medicine.  This practice does not necessarily abide by the conventional practice guidelines and our patients must be aware of this fact.

I agree that payment is considered due in full at the time of services or upon invoice. Payment may be made by cash, credit card/debit card, check or certified check.

I understand that Priority Health/CHM and its providers are OUT-OF-NETWORK providers with all insurance plans. I also will adhere (if applicable) to all conditions of the practice & providers practicing at Carolina Holistic Medicine opting out of Medicare and Medicaid.  We do secure non-refundable deposits for initial (new patient) and follow up appointments for non-membership patients.


Pursuant to HIPAA act of 1996, should I have any questions regarding the privacy of my medical records and how this
facility may use and disclose my health information I will visit: https://www.hhs.gov/hipaa/for-individuals/index.html  for more
information.

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(5) Special Medicare Opt-Out Waiver (only applies for those with Medicare)

This private contract agreement is between the physician and beneficiary noted above.

The beneficiary is a Medicare Part B beneficiary and is seeking services covered under Medicare Part B. The physician above has informed the beneficiary or his/her legal representative they have opted-out of the Medicare Program. The current Medicare opt-out period is from the date of signing for one full year (12-months). The physician noted above is not excluded from participating in Medicare Part B under §§1128, 1156 or 1892 of the Act. The beneficiary or his/her legal representative has read and agree to the following terms of the private contract by placing their initials by the items below:


I, or my legal representative, accept full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by this physician/practitioner;

I, or my legal representative, understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner;

I, or my legal representative, agree not to submit a claim to Medicare or to ask the physician/practitioner to submit a claim to Medicare;

I, or my legal representative, have been informed of the expected or known expiration date of the opt-out period; which is to a full 12-months after signing this document;

I, or my legal representative, understand that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted;

I, or my legal representative, enter into the contract with the knowledge that the beneficiary has the right to obtain Medicare- covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners who have not opted out;

I, or my legal representative, understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare;

I, or my legal representative, agree this contract was not entered into during a time when the beneficiary required emergency care services or urgent care services.

=============

I, the Medicare beneficiary or my legal representative accept full responsibility for payment of charges for all services furnished by Carolina Holistic Medicine. I, the Medicare beneficiary or my legal representative understand that Medicare limits do not apply to what Carolina Holistic Medicine may charge for items or services furnished.

I, the Medicare beneficiary or my legal representative agree not to submit a claim to Medicare or ask Carolina Holistic Medicine to submit a claim to Medicare. I, the Medicare beneficiary or my legal representative understand that a Medicare payment will not be made for any items or services furnished by Carolina Holistic Medicine that would otherwise been covered by Medicare as there was no primate contract and a proper Medicare claim will not be submitted.

I, the Medicare beneficiary or my legal representative sign this information sheet with the knowledge that I have the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not opted out of Medicare, and that I am not compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners who have opted out.

I, the Medicare beneficiary or my legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services paid for by Medicare. This information sheet cannot be signed by me, the Medicare beneficiary, or by my legal representative during a time when

I, the Medicare beneficiary, require emergency care services or urgent care services. However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 3044.28 of the Medicare Carriers Manual

I, the Medicare beneficiary, or my legal representative will receive or have received a copy (photocopy is permissible) of this information sheet, before items or services are furnished to me. Carolina Holistic Medicine will retain the original contract for the duration of this opt-out period. This contract remains in effect for two years, ending in January of 2017 at which time an additional 2 year opt out renewal will be in effect and when Carolina Holistic Medicine again opts out of Medicare, we will complete a new contract for each Medicare beneficiary and will expediently submit the appropriate affidavit(s) to all local Medicare carriers.  Every two years it auto renews.

[a separate CMS opt-out may have to be signed at time of visit]

(6) Electronic Transmission Disclosure and Acceptance

1. Member(s) understand(s) that the various forms of electronic transmission of information carry with them the unlikely yet possible risk of exposure and potential loss of that information for a variety of reasons.

2. By signing below, Member(s) indicate a desire to do business with Carolina Holistic Medicine (CHM) (Priority Health, LLC) or its affiliated clinics or providers via any or all of these electronic methods of communication, as indicated below:

  • Cell Phone calls & texting (including attached pictures when applicable)
  • Emails (including attached pictures when applicable)
  • Video Conferencing with CHM or their participating clinics or providers

3. By signing this document, Member(s) agree(s) to accept the risks inherent in the use of any of the above indicated communication methods for the purpose of diagnosis, treatment, or any other healthcare or business-related reasons.

Member(s) further agree(s) to indemnify and hold harmless CHM and its affiliated clinics or providers in the possible but unlikely event of a breach of confidential or protected information.

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(7) Messages, Email, & information shared with Family members:

I acknowledge that it is the policy of Priority Health/ CHM to leave reminder messages on my answering machine, email and/or cell phone text. I also acknowledge that lab reports may be reported directly to me in my follow up appointment and then mailed out (if necessary).

I acknowledge that if I give permission to discuss my health information and plan with a family member I will provide front desk staff with names of family and contact information and LIMITATIONS to what can or should be discussed (this will be placed in your EHR).

I acknowledge that this waiver is fully understood in its content. I further attest to reading and understanding the Cancelation Policy, all opt-out policies and I have read and understand the HIPAA NOTICE OF HEALTHCARE PRIVACY PRACTICES at Priority Health, LLC and Carolina Holistic Medicine.  I further attest to understanding our Patient Handbook details and no-show, last minute reschedule or cancellation policy and our non-refundable deposit policy.

 

October 24, 2021

 

First Patient Name

First Name*

Last Name*

Phone*
First Patient Date of Birth*
First Patient Signature*
Second Patient Name

First Name*

Last Name*
Second Patient Date of Birth*
Third Patient Name

First Name*

Last Name*
Third Patient Date of Birth*
Fourth Patient Name

First Name*

Last Name*
Fourth Patient Date of Birth*
Fifth Patient Name

First Name*

Last Name*
Fifth Patient Date of Birth*
Sixth Patient Name

First Name*

Last Name*
Sixth Patient Date of Birth*
Seventh Patient Name

First Name*

Last Name*
Seventh Patient Date of Birth*
Eighth Patient Name

First Name*

Last Name*
Eighth Patient Date of Birth*
Ninth Patient Name

First Name*

Last Name*
Ninth Patient Date of Birth*
Tenth Patient Name

First Name*

Last Name*
Tenth Patient Date of Birth*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Electronic Transmission Disclosure and Acceptance

1. Member(s) understand(s) that the various forms of electronic transmission of information carry with them the unlikely yet possible risk of exposure and potential loss of that information for a variety of reasons.

2. By signing below, Member(s) is/are indicating a desire to do business with Carolina Holistic Medicine (CHM) (Priority Health, LLC) or its affiliated clinics or providers via any or all of these electronic methods of communication, as indicated below:

·  Cell Phone Texting (including attached pictures when applicable)

·  Emails (including attached pictures when applicable)

·  Video Conferencing with CHM or their participating clinics or providers

3. By signing this document, Member(s) agree(s) to accept the risks inherent in the use of any of the above indicated communication methods for the purpose of diagnosis, treatment, or any other healthcare or business related reason.

Member(s) further agree(s) to indemnify and hold harmless CHM and its affiliated clinics or providers in the possible but unlikely event of a breach of confidential or protected information.


Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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