Address *

Street Address *

City *

State *

Country

Postal code *

I, the undersigned, have insurance coverage with the below mentioned company, and assign directly to Prolific Well Providers all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Prolific Well Providers to release all information necessary to secure the payment benefits. I give permission to Prolific Well Providers to release information to my other health care providers. I authorize the use of this signature on all my insurance submissions.

This Document Constitutes an Agreement: We have written this document to inform you about our practice, to ensure you understand our professional relationship, and to obtain your informed consent in this relationship. Your informed consent is important not only because it protects both parties in this agreement, but also because it helps you to feel empowered in your own healing process. When you sign this document, it will authorize us to initiate care and commence treatment in accordance with this document. Please read this document carefully and bring any questions you might have to your first meeting with a Prolific Well practitioner. Please also be responsible for maintaining clarity and communication regarding your ongoing informed consent. If at any time you are uncomfortable or dissatisfied with your care or treatment, for any reason, please let us know immediately.

Purpose of Treatment & Therapeutic Orientation: Prolific Well is an integrative and collaborative medical group practice dedicated to helping you achieve and maintain optimum health. We will help you as best we can to resolve your complaints and to achieve your health goals. We understand healing as a natural process, and our fundamental goal in relation to this is to support, facilitate, and empower you in your own healing journey.

Naturopathic Medicine Practice & Limitations: Naturopathic Physicians currently practicing at Prolific Well include Dr. Evelyn Le (NT1528637436). In the State of Washington, naturopathic medical practice includes the art and science of diagnosis, prevention, and treatment of disorders by stimulation of the natural processes of the human body. The practice of naturopathic medicine includes the prescription, administration, dispensing, and use of: nutrition and food science, homeopathy, hygiene, immunizations & vaccinations, contraceptive devices; non-legend medicines including vitamins, minerals, botanical medicines, homeopathic medicines, and hormones; and legend drugs with the exception of Botox and certain controlled substances. The practice of naturopathic medicine also includes manual manipulation, physical modalities, minor office procedures, common diagnostic procedures, and suggestion. In the State of Washington naturopathic physicians may not treat malignancies except in collaboration with a Medical Doctor (MD) or Osteopathic Physician (DO). Therefore, if you have cancer, or suspect you have cancer, we require you be under the care of a board-certified oncologist or other MD or DO with sufficient experience working with cancer. If you have cancer or suspect you have cancer, by signing this document you hereby agree to remain under the continuing care of a qualified MD or DO and you agree that your relationship with this MD or DO shall be the primary therapeutic relationship, and that the care you receive at Prolific Well shall be secondary and supportive of your general health and shall not be understood as treatment of a malignancy.

Health and Wellness Coaching and Education: In addition to the aforementioned professional medical services, Prolific Well also offers health and wellness coaching and education services that are not conventionally recognized as the practice of medicine. We primarily offer these coaching and education services both through classes and events and via individual sessions. Some of our health coaches are licensed medical professionals but in this capacity they are acting solely as health coaches. What is shared via health and wellness coaching and education services is intended for informational and educational purposes only, and is not intended nor suited to be a replacement or substitute for professional medical diagnosis and treatment or for professional medical advice relative to a specific medical question or condition. You can ask our health coaches for advice and guidance about healthy living, including diet and daily habits and lifestyle choices, but please do not ask for medical advice or a specific medical or dietary or lifestyle prescription. You can ask our health coaches about disease states and health issues in general, but please do not ask for a medical opinion or diagnosis about your particular condition. You can talk through stressors in your life with our health coaches, and how to handle these, but please do not ask for guidance that would be considered therapy or ask our coaches for advice about specific decisions in your life. Health coaches are allowed to give general advice on topics such as stress reduction, time management, lifestyle changes, meditation, interpersonal relationships, and many other topics that would not be considered the practice of medicine or mental health. For example, a coach can teach you how to take control of your mental state in a stressful situation. But he or she cannot guide you through exercises that are specific to Cognitive Behavioral Therapy.

Electronic Communications: By signing below, I am authorizing Prolific Well to communicate with me via unencrypted email and text (SMS) messages. I understand that these electronic communications may include protected health information of a limited nature so that Prolific Well may communicate more efficiently with me about scheduling, care coordination, billing, invoices and receipts as well as marketing and general communications. I understand that Prolific Well and its partners have taken considerable efforts to protect the personal health information of patients, but that email and text messages are not a completely secure means of communication. If you would prefer not to communicate via SMS with us you may reply STOP to any SMS message. However please be advised that you will then be responsible for missed communications from your care team. Message & data rates may apply for any messages sent or received.

Confirmation of Review of Notice of Privacy Practices: By signing below I confirm I have reviewed and understand the Prolific Well Notice of Privacy Practices, that I understand that I am entitled to keep a copy of the notice for my records, and that a copy is for download on the Prolific Well website.

Having read and understood the foregoing: By signing below you are asserting your understanding of and agreement with the entirety of this agreement and voluntarily consenting to treatment as outlined here, while also acknowledging that you are free to withdraw consent and to discontinue treatment at any time. By signing below you are authorizing physicians and other practitioners at Prolific Well to provide all examinations, treatments and/or diagnostic procedures which now or during the course of your care they deem advisable. By signing below you are acknowledging that while the course of treatment is designed to be helpful, it may at times be difficult and uncomfortable, and that there is no guarantee that there will be any benefit from treatment. By signing below you are agreeing that you and no one else is responsible for your own healing and that maximum benefit will occur with consistent treatment and compliance and when you take full responsibility for your own healing journey. By signing below you acknowledge that Prolific Well is responsible only for the failure to perform your treatment with appropriate care. By signing below you are certifying that you have read and understood all preceding information and you are committing to immediately notifying your Prolific Well practitioner or other Prolific Well staff if you have any questions or should concerns arise at any time during the course of your treatment.

Financial Responsibility: By signing this form you are attesting that you understand and agree that you are fully responsible for payment for all services that you receive.

Payment at Time of Service: We offer a discount when you pay at the time of service. Please see the Pricing page on our website for further details. The amount of the discount represents the savings in not having to bill an insurance company. If you want to pay at the time of service, please let us know when you schedule your appointment.

Insurance Billing: Our providers are credentialed with numerous insurance companies. Please see the Insurance page on our website for further details. If we have accurate insurance information, we will bill your insurance company for you. We require a copy of your driver’s license/identification and current valid insurance card at the time of your appointment. Insurance is a contract between you and your insurance company. We are NOT a party to this contract. If we believe that our clinician is in-network with your insurance and the service we are providing is covered by your insurance then we will attempt to bill your insurance and you will be responsible for timely payment of copays and coinsurance or for the entire cost of the service if you have not yet met your deductible for the year. If your insurance does not pay we will make a reasonable attempt to do what we can to get them to pay but you are ultimately responsible for payment.

Out of Network: We are only in-network with a select few insurance plans. If we are out of network with your plan you will have to pay cash for our services. The plans we are out of network with include but are not limited to the following: Aetna, Cigna, United Health, Kaiser HMO and any other HMO plan, Tricare, VA, and Medicaid including Molina, Amerigroup, Apple Health. If you are covered by these insurers or by any other plan for which we are out of network then you will have to pay cash for our services. If you pay at the time of service you will receive the time of service discount.

Medicare: Medicare does not recognize our physicians or any of our other clinicians. If you have Medicare Part B then you will likely have to pay cash for our services even if you have other insurance. Medicare Advantage and Medicare Gap plans will not pay for our services. The one limited exception is if you have one of a small number of top of the line plans that pay primary to Medicare. But even the best plans do not cover the services of all of our clinicians. The services offered by our physical therapists are always cash-pay for Medicare patients. It is up to you to determine if your insurance will pay for any given service and you are ultimately responsible for payment for all services. Also please note that Medicare will not pay for labs or medications if they are prescribed by our physicians so many of our Medicare patients work with other doctors to manage their labs and medications.

L&I Workers Comp: We do not work with L&I claims. If your condition is related to an L&I claim you will have to pay cash for our services.

Auto/MVA/PIP: We do not work with auto or other accident insurance claims. If your condition is related to an auto or other accident you will have to pay cash for our services.

Account Balances and Payments: At Prolific Well our policy is to keep a credit or debit card on file as a convenient method of payment for the portion of services that your insurance does not cover. We keep your credit card on file to be used in the following instances:

If we are billing an insurance company for you we will charge your card on file for copay, coinsurance and deductible amounts per your insurer’s Explanation of Benefits. We will charge your card on file only after the claim has been filed and processed by your insurer and posted to your account by your insurance company.

If you are self-pay and you pay at the time of service then you qualify for the Time of Service Discount. We will apply the discount and charge your card on file on the day of your appointment or as soon as we have the billing from the clinician.

We will charge your card on file for non-billable service payments, as outlined in the non-covered services agreement, and for other services not covered by insurance as outlined in our financial policy.

If you miss an appointment or cancel an appointment within 24 hours of the visit time please reach out to us to explain any extenuating circumstances that might have caused this. Otherwise we will charge your card on file for the no-show / late-cancel fee (see below) per this Financial Policy.

We will charge your card on file for any supplements or other medicinals that you purchase from our medicinary.

We will credit your card on file any money due for refunds or overpayments.

Prolific Well is not responsible for any fees associated with any overdraft charges you might incur from your financial institution.

If you do not have a card on file or we are unable to process your card you will be responsible for a $20 finance charge that shall be incurred monthly whenever any charges are greater than 30 days past due. Past due balances older than 120 days will be sent to a collections agency. Partial payments or payment plans must be negotiated with Prolific Well in advance.

Cancellations: There is a $100 charge for all missed appointments or for cancellations made less than 24-hours notice prior to the visit start time. This fee is not billable to insurance. At our discretion, unavoidable emergencies may be considered reasonable exceptions. If you miss three appointments or have three late cancellations (excused or unexcused) you may be dismissed from the practice.

Non-Covered Services: Prolific Well charges separately for services that are not normally covered by insurance. These services include personalized care within our collaborative care model with access to all team members, priority access to your preferred group physician for more personalized visits and communication, patient portal communications with your physician and collaborative care team, prescription refills and support, billing support, pre-authorizations for medications and imaging, ordering and processing of conventional and non-conventional lab testing (you pay the lab company directly but we facilitate the process), medical records support and coordination, supplement discounts at our in-house dispensary, and health and wellness education. For more information see our separate Non-Covered Services Agreement.

Special Fees: In addition to the above fees for non-billable services we reserve the right to charge separately for the following services. These fees are also not billable to insurance.

MVA, Disability, FMLA, & Other Reports $50.00

Medical Records $26 clerical fee + per page fee

Returned Checks $50.00

Supplement Sales: All supplement purchases are final.

At Prolific Well we are committed to providing exceptional care that goes well beyond what is conventionally available. Our team of experienced clinicians makes every effort to really understand you and your situation and to identify and resolve the root causes of your illness or injury. Our goal is not just to treat your symptoms but also help you optimize your health and to empower you in your healing journey.

Unfortunately, this kind care is significantly undervalued within the conventional medical system. Hence in order support this unconventionally exceptional care we charge additional fees for services that are not generally covered by insurance. These non-billable service fees allow us to stay in business without compromising on the quality of care we provide.

Per Visit Fees for Non-Covered Services

$45 after every physician visit.

This is our default option. This flexible option provides the following non-covered services for a two-week period following each physician visit:

Personalized care with lab interpretation, vitamin and nutrients recommendations.

Prescription refills and support

Patient portal communications with Dr. Evelyn.

Insurance billing and support, including pre-authorizations for medications and imaging

Ordering and processing of conventional and non-conventional lab testing (you pay the lab company directly but we facilitate the process)

Medical records support and coordination

Note: The communication and support that is paid for via these fees is not a substitute for visits with your physician or other covered services. Some questions cannot be answered without a visit. Some prescriptions, referrals and even some paperwork cannot be completed without a visit. Some paperwork that can be completed outside of a visit but is especially time consuming will result in a separate paperwork fee per our financial policy.

Our policy requires keeping a credit or debit card on file as a convenient payment method for services not covered by insurance. You are receiving this form because you have requested to maintain different cards on file for Medical Services, Product Sales, and/or the Non-Covered Services Agreement.

Card Usage Instances:

Insurance Billing: Your card will be charged for copays, coinsurance, and deductibles according to your insurer’s Explanation of Benefits, once claims are processed.

Self-Pay Discounts: For Time of Service Discounts, your card will be charged on the appointment day or upon receipt of billing.

Wellness Plans & Non-Covered Services: Charges apply as outlined in the Non-Covered Services Agreement and our financial policy.

Missed Appointments: No-show or late-cancel fees will be charged unless extenuating circumstances are communicated.

Product Purchases: Charges for supplements or medicinals from our medicinary.

Refunds & Overpayments: Any refunds or overpayments will be credited back to your card.

Finance Charges:

A $20 monthly finance charge applies if no card is on file and charges are over 20 days past due. Balances over 90 days past due will incur a 30% collections fee.

Agreement:

I authorize Prolific Well (the "Practice") to charge my card (the "Payment Method") for any patient balance due for services provided to the patient(s) listed on this Authorization. I acknowledge:

Charges will only apply to patient responsibilities not covered by insurance.

Receipts will be provided for each payment.

Charges apply to services for the listed patient(s) and any linked accounts.

If charges exceed the maximum amount, I will be billed for the remaining balance.

Payment information is securely stored by the Practice and/or trusted service providers.

I may cancel this authorization anytime by contacting the Practice.

Changes to this authorization will automatically amend it.

All provided information is true and accurate, and I certify I am an authorized user of the payment method.

Please input your card information below. This information will be securely stored by third-party processors.

As required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by our organization, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the organization, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for equipment or supplies coverage may require that your relevant protected health information be disclosed to the health plan to obtain approval for coverage.

Healthcare Operations: We may use or disclose, as‐needed, your protected health information in order to support the business activities of our organization. These activities include, but are not limited to, quality assessment activities, employee review activities, accreditation activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to accrediting agencies as part of an accreditation survey. We may also call you by name while you are at our facility. We may use or disclose your protected health information, as necessary, to contact you to check the status of your equipment.

We may use or disclose your protected health information in the following situations without your authorization: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, Inmates, Military Activity, National Security, and Workers’ Compensation. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to Object, unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or this organization has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights: Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Our organization is not required to agree to a restriction that you may request. In general we will not agree to any restriction that contradicts our policies as stated in our Informed Consent Agreement and Membership Services Agreement. If Prolific Well believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, e.g., electronically.

You may have the right to have our organization amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

State Mandated Exemptions:

Washington State law requires us to disclose health information to the Department of Labor & Industries or a self-insured employer for workers’ compensation or crime victim claims.

We can disclose health information to an employer about light duty work without a patient authorization.

We can disclose health information to an employer without a patient authorization if that information is about a workplace injury or illness, a workplace medical surveillance, or a return-to-work examination.

Because these disclosures to the department or self-insurer are required by law, patients cannot object to or request that we restrict those disclosures (45 CFR, 164. 522(a) (1) (v)).

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. This notice was publish and becomes effective on April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information, if you have any questions concerning or objections to this form, please let us know.

Associated companies with whom we may do business, such as an answering service or delivery service, are given only enough information to provide the necessary service to you. No medical information is provided.

We welcome your comments: Please feel free to call us if you have any questions about how we protect your privacy. Our goal is always to provide you with the highest quality services.

I have read and been notified of this Privacy Practices that describes how my health information is used and shared. I understand that Prolific Well has the right to change this notice at any time, and that they will provide a copy of the HIPAA NOTICE PRIVACY PRACTICES at my request.

Consent to Treatment

It is our philosophy that patients should have full disclosure when receiving any type of health care. We therefore ask that you read and sign the following consent. We also feel that any individual should request the same full disclosure from any other healthcare provider and their proposed treatment plan. Educated choices are the only choices.

I understand that as a patient of Prolific Well providers. I will receive an initial evaluation and thorough discussion of treatment options. The goal of the initial evaluation process is to determine the best course of treatment for me.

I understand that typically, treatment is provided over the course of several weeks to months. I understand that all information shared with the healthcare provider is confidential and that to know information will be released without my consent. During the course of treatment, it may be necessary for my providers to communicate with other healthcare practitioners. I understand that consent to release information is given through written authorization. Verbal consent for release of limited and essential information may be necessary in special circumstances.

I understand that while treatment may provide significant benefits, it may also pose risks. Short of overt negligence, I agree to hold Prolific Well providers harmless in case of undesirable effects of undertaking or discontinuing treatment. I also understand that I may stop treatment at any time.

Please note: If applicable, co-pays are due at each visit. I also understand that unless other arrangements have been made ahead of time. Payment in full is due at the end of each treatment.

I also understand that a given provider may have financial interest in any referral given to another provider in the clinic. As an owner, partner, group owner or shareholder.

If a provider in our office recommends other forms of treatment, it is at your discretion to choose one of our in-office providers or an external provider. It is your right to have a chaperone in the room during your exam. We will provide someone upon request.

If I have any questions regarding this consent form or about the services offered. I am encouraged to discuss them with the treating healthcare provider I have read and understand the above. I consent to participate in the evaluation and treatment offered to me by the individual healthcare providers. I understand that I have the right to suspend any treatment at any time. But that if the suspension of treatment is against medical advice that the consequences of my decision are my own responsibility.

Consent for Examination

I understand that various physical exams are conducted by the doctors and therapist at Prolific Well.

I understand that as part of the physical exam I may be asked to wear a gown to disrobe. Or to expose the body parts.

I understand that this exam may include physical contact and or exposure of various body parts that may be considered sensitive or private (e.g. genitalia).

I understand that it is my right to refuse any form of examination prior to or during the examination for whatever reason.

I understand that this refusal may compromise the capacity of the doctor to diagnose my health problem.

I understand that if for whatever reason, if I am uncomfortable about during an exam prior to or during, I can suspend and reschedule the exam or a portion of that exam to the future date.

I understand that Prolific Well has offered a chaperone to be present and will provide a chaperone upon request. This request may be made at any time before or during this examination or any future examination.

Signing this form confirms that I understand all of the above facts and that they pertain to today's examination and future examinations.

We at Prolific Well want to be as thorough as possible, while respecting your feelings and privacy.