CONSENT AND UNDERSTANDING This consent is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of your rights for privacy with respect to your healthcare information. HIPAA Privacy Authorization Form **Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)** **1.
Authorization** I authorize
WELLNESS COUTURE, LLC to
use
and
disclose
the
protected
health
information
described
below
to: (PATIENT / GUARDIAN NAME) **2. Effective
Period** All past, present, and future periods. **3.
Extent
of
Authorization**
I
authorize
the
release
of
my
complete
health
record. 4. This
medical
information
may
be
used
by
the
person
I
authorize
to
receive
this
information
for
medical
treatment
or
consultation,
billing
or
claims
payment,
or
other
purposes
as
I
may
direct. 5. I
understand
that
I
have
the
right
to
revoke
this
authorization,
in
writing,
at
any
time.
I
understand
that
our vocation
is
not
effective
to
the
extent
that
any
person
or entity
has
already
acted
in
reliance
on
my
authorization
or
if
my
authorization
was
obtained
as
a
condition
of
obtaining
insurance
coverage
and
the
insurer
has
a
legal
right
to
contest
a
claim. 6. I
understand
that
my
treatment,
payment,
enrollment,
or
eligibility
for
benefits
will
not
be
conditioned
on
whether
I
sign
this
authorization. 7.
I
understand
that
information
used
or
disclosed
pursuant
to
this
authorization
may
be
disclosed
by
the
recipient
and
may
no
longer
be
protected
by
federal
or state
law. Consent for Care: I, with my signature, authorize WELLNESS COUTURE, LLC, and any employee working under the direction of Dr. Cynthia Barrett, PT, DPT, CSCS, CNS to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services and supplies related to my health (or the identified person) and may include (but is not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of herbal, devices, equipment or other items required and in accordance with referrals from healthcare professionals. This consent includes contact and discussion with other healthcare professionals for care and treatment. Telehealth Agreement: - I authorize Wellness Couture, LLC to perform telehealth services for assessing and diagnosing my medical condition using telecommunications programs.
- I confirm that medical professionals can reach me with video calls or audio calls as part of the online sessions.
- I acknowledge that in this type of platform technical difficulties may happen which might cause a slight delay or might need rescheduling.
- I understand that it is my responsibility to provide all necessary information like signs and symptoms, medical history, current condition to the health professional.
- I confirm that telehealth services require the collection of personal medical data to the health professional remotely which means they are based on any area.
- I confirm that the information I provided here will not be shared with others without my consent.
- I confirm that all information I provided in this online session is accurate and true.
Appointments and Cancellation Policy: I agree to keep all scheduled appointments and be on time. If I cannot attend a scheduled session, I will contact WELLNESS COUTURE to cancel and/or reschedule. Al carte sessions will incur a $100 fee if session is not cancelled 24 Hrs. prior to your session. NOTE: 2 Nutrition Sessions per month are included in your program and if not used within that month, will not roll over. I understand if I am more than 30 minutes late, I forfeit my session. Financial Policy: We appreciate you choosing us for your health care. We will adhere to the following financial policy in order to consistently deliver high quality care and services. The patient/responsible party assumes responsibility to ensure that the financial obligation is fulfilled for the health care services received: ● I understand that I am responsible for all fees for services; due at the time the service is provided. Forms of accepted payment include cash or check, and Health Savings Account/Flexible Spending Account. I will make payment when checking in for my appointment. It is my responsibility to verify applicable coverage when using a Health Savings Account/Flexible Spending Account prior to receiving the services. I consent to assign all payments for services directly to this practice. I further consent to the use for any practice operational needs as identified by WELLNESS COUTURE, LLC. ● I authorize Wellness Couture to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described below, for the amount indicated below, and valid for additional orders (recommended supplements, products, etc). by Wellness Couture, LLC. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. NOTE: The card you provide will be charged $250 the first of every month for your membership. NUTRITION SERVICES Nutrition Program with Genetic Panel | Mini Diet Dx ⎜ Nutrigenomic Test - $2695 • FOLLOWING A $250 MONTHLY MEMBERSHIP AFTER THE FIRST THREE MONTHS • 1 NUTRITION EVALUATION VISIT (1st visit only) • 2 NUTRITION FOLLOW-UP VISITS PER MONTH DESCRIPTION OF NUTRITION SERVICES 1 Nutrition Evaluation followed by subsequent Nutrition Follow-up visits to provide a comprehensive individualized custom plan of action to reach individual nutrition goals NUTRITION EVAUALTION • 1-Hour Nutrition Evaluation evaluating in-depth medical history from childbirth to present health status • Remote via phone or video chat NUTRITION MONTHLY FOLLOW-UP VISITS • 2 - 30-Minute subsequent Follow-up visits per month • A Comprehensive nutrition plan is provided formulating a plan specific to your makeup tailoring the program for your body as it is not a 1-size-fits-all approach: 1. Providing realistic plan of care with seamless integration into and without compromising current lifestyle
2. Executing the Nutrition plan and measuring against your goals
3. Tracking your progress and checking in 2x a month
4. Each visit adjusting the plan as necessary • Remote via phone or video chat Additional Specialty Tests to evaluate your individual microbiome may also be recommended based upon clinical presentation. GENETIC PANEL • MINI DIET DX ⎜ NUTRIGENOMIC - $595 Everyone’s optimal diet is different and is based on their genes and current state of health. In this mini panel, we address questions such as: • Do you have issues with oxalate, salicylate, histamine, or sulfur metabolism?
• Are you predisposed to heart disease or genetically high cholesterol and does that impact how much fat you should eat?
• Would a high fat diet work well for weight loss or might it result in an increased risk for cardiovascular disease?
• Are you able to consume diary products without increasing inflammation? The answers to these questions will help you begin to learn what is the best diet for you by uncovering inflammatory triggers in your food and providing lifestyle, supplement and diet changes that will significantly improve your health. GUT HEALTH SIDES – ADD ON THE WELLNESS STOOL PANELS GI-MAP | GASTROINTESTINAL MICROBIAL ASSAY PLUS - $795 How can you OPTIMIZE your GUT MICROBIOME by unlocking your Gene Mapping through GI-MAP TESTING? Gastrointestinal Microbial Assay Plus or the GI-MAP™ test is an innovative clinical tool that measures gastrointestinal microbiota DNA from a single stool sample with state of the art, quantitative polymerase chain reaction (qPCR or real-time PCR) technology. Since the GI-MAP is a DNA-based test, results reflect the levels of pathogenic strains carrying the toxin genes, not the levels of any toxins that may be produced. The GI-MAP was designed to detect microbes that may be disturbing normal microbial balance or contributing to illness as well as indicators such as: • Digestion
• Absorption
• Inflammation
• Immune function What does the GI-MAP Test? The GI-MAP tests for PATHOGENS known to cause intestinal gastroenteritis: • Parasitic Pathogens
• Viral Pathogens
• Normal Commensal Bacteria
• Opportunistic Bacteria
• Fungi/Yeast
• Viruses
• Parasites
• Worms
• Intestinal Health Markers of Digestion/Malabsorption
• Crucial GI Markers of Digestion/Malabsorption
• Antibiotic Resistance Genes Who is a GOOD CANDIDATE for GI-MAP Testing? GI-MAP Testing may be indicated if you suffer from or have a family history of one of the following: • Intestinal infections and proinflammatory dysbiosis
• Food allergens and/or sensitivities
• Toxins and certain drugs (e.g., non-steroidal antiinflammatory drugs [NSAIDs], Antibiotics)
• Fecal contamination of food, water and liquids (eggs, poultry, undercooked meat, raw shellfish, raw milk/dairy products, vegetables, and unpasteurized juice)
• Swimming in Contaminated water (Ocean, lakes, streams, ponds, pools)
• Skin Contact with Contaminated Soil
• Pets - Cats and Dogs
• Sexual contact
• Inflammatory bowel disease
• Impaired Immune function
• Bloody diarrhea, Hemorrhagic colitis, may progress to hemolytic uremic syndrome (HUS)
• Polyps
• Diverticulitis
• Colorectal cancer
• Diarrhea in infants and children spreading to adults
• High dietary intake of sugar, starches, and fungi
• Gall Stones
• Cystic Fibrosis
• Vegetarians/Vegans
• Poor Diet
• Dysbiosis
• Maldigestion or hypochlorhydria
• Celiac
• Upper GI Bleeds that cause Iron deficiency Anemia VIOME | GUT INTELLIGENCE TEST - $595 NOTE: TEST IS NOT AVAILABLE FOR NY STATE RESIDENTS TO ORDER IN OR MAIL OUT FROM NY STATE The Viome Gut Intelligence Test is a Stool Test that captures everything that is happening in the gut microbiome using metatranscriptomic sequencing technology allows us to see every microorganism in your gut microbiome and analyze the activity of these microorganisms. By analyzing the genes that microbes express, we can identify which metabolites they produce – in other words, we can determine their role in your body’s ecosystem. Viome Gut Intelligence Test provides the following individualized recommendations to fine-tune the function of their gut microbiome to minimize production of harmful metabolites and maximize the production of beneficial ones. Test results reveal: • Foods to Avoid and Minimize
• Superfoods
• Supplements
• Active Microbes URINE PANEL ORGANIX COMPREHENSIVE TEST - $595 Organic acids are metabolic intermediates that are produced in pathways of central energy production, detoxification, neurotransmitter breakdown, or intestinal microbial activity. Marked accumulation of specific organic acids detected in urine often signals a metabolic inhibition or block. The metabolic block may be due to a nutrient deficiency, an inherited enzyme deficit, toxic build-up or drug effect. Several of the biomarkers are markers of intestinal bacterial or yeast overgrowth. The Organix® Comprehensive nutritional test profile provides vital patient information from a single urine specimen. This organic acids nutritional test is valuable for determining: • Functional vitamin and mineral status
• Amino acid insufficiencies like carnitine and NAC
• Oxidative damage and antioxidant need
• Phase I & Phase II detoxification capacity
• Functional B-complex vitamin need
• Neurotransmitter metabolites
• Mitochondrial energy production
• Methylation sufficiency
• Lipoic acid and CoQ10 status
• Markers for bacterial and yeast overgrowth
• Must have Nutrition Membership to purchase Urine Testing services
OTHER TEST IMMUNOLYTICS | MOLD TEST KIT - $283+ ImmunoLytics is the leading mycology lab used by doctors, pharmacists, and environmental specialists to analyze mold samples and help evaluate patients’ homes, school and work environments, a vital step toward a healthier life. ImmunoLytics lab utilizes cutting-edge mold analysis focusing on mold identification and mold counts. The information our mold test kits and analysis can provide is essential for helping determine if contamination is present and what steps must be taken if it is. ImmunoLytics complete analysis can tell homeowners, doctors or others exactly what they are dealing with in regard to mold type. This is vital for putting into place the proper remediation protocol. Agreement I have read and understand the Consent and Financial Policy stated above and agree to accept full responsibility as described above. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. I Agree Patient / Guardian November 21, 2024 | 