Policies and Procedures
(I) INFORMED CONSENT
I hereby consent to treatment for me or my child by providers at The Peirson Center for Children.
TREATMENTS OFFERED
Procedures and treatments MAY (or may not) include the following:
By signing this form, you consent to the above procedures and treatments, as indicated. You will have the opportunity to discuss with your practitioner(s) the various types of treatments proposed for you or your child’s condition, and the purpose and objectives of these procedures will be explained.
A cure or improvement from treatment is not guaranteed.
POTENTIAL RISKS OF TREATMENT
There are some rare but potential risks to treatment and procedures. Some of these risks include, but are not limited to the following:
Note that doing an individualized vaccine schedule may place yourself, your child, or other families at risk of contracting certain infectious diseases, some of which may cause permanent symptoms and/or death.
PRIMARY CARE
Please note that the practitioners at the Peirson Center for Children are not acting as your primary care physician and we require that you have a primary care physician. If you or your child has a serious health problem that requires immediate attention you should call your primary care doctors(s), call 911, or have someone take you or your child to the nearest hospital emergency room. Please note that we do NOT have an after-hours answering service or 24-hour call shifts.
If you notice an adverse effect from one of the components of your health plan, you should discontinue it and contact our office.
TERMINATING CARE
We reserve the right to terminate the doctor/patient relationship at any time for any reason, and are under no obligation to state the reason for discontinuing care.
(II) PRIVACY POLICY AND ACKNOWLEDGMENT
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain privacy rights concerning your healthcare information. Under this law, your healthcare provider generally cannot give your information to your employer, use or share your information for marketing or advertising purposes, or share private notes about your mental health counseling sessions without your written consent. As one of your providers, it is our responsibility to keep your information safe and secure. A record will be kept of the health services provided to you. This record will be kept confidential and will NOT be released to others unless required by law or specifically directed by you or your legal representative.
Your record MAY be shared in the following ways:
ACCESSING YOUR OWN MEDICAL RECORDS
You may look at your child’s health record online or request a copy at any time in writing. You may be charged an administrative fee for printed or faxed copies of your record, and it can take up to 30 days for us to deliver your records. Your health records will be kept for a minimum of 7 years after the date of your last visit.
You have the right to make requests on how and with whom your information is shared.
COMMUNICATIONS
E-MAIL & MESSAGES:
E-mail is not confidential. We therefore allow patients to send secure messages through our secure patient portal. Any messages sent will be added to your patient record. Although creating a portal account is free, please note that there may be a fee for care management done through the portal or by phone outside of an office visit. Messages sent through the portal are not a substitute for care.
We ask that you limit messages you send to your practitioner and contact our office manager for questions regarding your child’s care plan or other aspects of coordinating care for your child.
ON CALL:
Please note that we do NOT have an after-hours answering service or 24-hour call shifts. There is no “on call.”
TELEMEDICINE & PHONE/WEB APPOINTMENTS:
Telemedicine and Web/Phone Appointments involve electronic communication of your/your child’s personal medical information to a practitioner who may be located in another state or country. We take precautions to ensure your privacy, but do not make any guarantees regarding the HIPAA-compliance of the technology used.
In the absence of in-person visits on a semi-regular basis patients will work with the practitioners at the Peirson Center for Children on a consultant/client context, wherein the practitioners do not prescribe medication, but offer general health “coaching” services.
Phone/web appointments are not a substitute for in-person care. If you anticipate primarily engaging the Peirson Center for Children through such remote appointment types, then please also establish care with a provider local to you, who you can see in person.
LIST SERV:
ALL active patients will be automatically added to our listserv. We reserve the right to send e-mails very infrequently with important clinic updates (such as holiday closures and policy changes). We ask that all active patients stay subscribed to this listserv, so that you can receive important information.
RECORDINGS:
Please do not make video or audio recordings of your visits in part or whole without explicitly obtaining the written consent of your practitioner at each visit. Your provider has the right to refuse recordings. If you do record sessions (with permission) in part or whole, you agree to use said recordings for personal use only. They may not be shared with others, posted to the internet, quoted in publication, or used in litigation against your practitioner.
(III) FINANCIAL POLICY
PAYMENT
Payment for all office visits (whether or not you have insurance) is due at the time of scheduling your child’s appointment.
HEALTH INSURANCE
The practitioners at the Peirson Center for Children are not currently recognized as in-network providers under any insurance plans and do not plan to ever be. We do not guarantee any reimbursement or coverage from your insurance provider. Most insurance plans do not reimburse for telephone or telemedical appointments.
At your request we can send you a superbill for your appointment that you can submit to your insurance company for potential reimbursement.
MEDICAID and MEDICARE, TRICARE, AND V.A. (MILITARY)
Please note that state or federal programs like Medicaid, Medicare, and Tri-Care neither cover nor encourage services provided by an out of network provider. They likewise will not pay for lab work ordered by an out of network provider. By becoming a patient at this clinic, you agree NOT to submit superbills or receipts to your state or federal insurance company for services provided at this clinic. (Doing so could get your health insurance suspended.) Being a patient here means working entirely out of the Medicaid/Medicare/Tri-Care system. You will be responsible for all expenses incurred out of pocket. You may be able to get these services covered by your insurance if you see another doctor or clinic; call Medicaid/Medicare/TriCare for information on how to find a provider covered by your plan.
PHONE CALLS AND ELECTRONIC MESSAGES
Simple questions (clarification of supplement dosing, etc.) will be addressed free of charge. Issues managed by phone or through portal message that include either a new complaint, request for a new prescription, changes to a treatment plan, management of a new symptom, or any matter that takes more than a minute of the practitioner’s or staff’s time will incur a fee.
MISSED APPOINTMENTS AND LATE CANCELLATIONS
For new patient visits: $50 will be charged for missed appointments or cancellations made with less than 24 hours’ notice. This fee must be paid whether you reschedule or not.
Follow up visits: You will be charged a $20 fee for any missed appointments or cancellations made with less than 24 hours’ notice.
LATE ARRIVALS
We understand that sometimes patients arrive late for appointments due to unforeseen circumstances. As a courtesy to other patients and to your practitioner, we must nevertheless end your appointment at the scheduled time if you arrive late. (For example, If your appointment was scheduled for 1-1:30 pm and you arrive at 1:10, the visit will still end at 1:30 pm). You will still be charged for a full visit, and may be required to make another appointment to finish whatever wasn’t covered in your truncated session.
If you are more than 15 minutes late for your appointment, we reserve the right to cancel your appointment and send a $20 no-show fee invoice ($50 for new patient visits) .
We reserve the right to dismiss from the practice patients who no show or late cancel more than three times, even if the appropriate fees are paid.
SUPPLEMENTS
Your provider may prescribe medications, supplements, botanicals, homeopathics, and other products that may be purchased through our online shop, or elsewhere.
Most insurance companies do not cover the natural pharmacy items we prescribe and dispense, though some FSA and HSA accounts will. We do not guarantee coverage.
BLOOD TESTS AND LABORATORY TESTS
Your provider may order laboratory testing (blood, urine, stool tests, etc) as indicated. We do not guarantee that your insurance will cover these tests in part or whole. Checking coverage is the patient’s responsibility. Call your insurance company for more information.
I hereby consent to treatment for me or my child by providers at The Peirson Center for Children.
TREATMENTS OFFERED
Procedures and treatments MAY (or may not) include the following:
- Medical nutrition and dietary supplementation
- Botanical medicine: teas, alcoholic tinctures, capsules, tablets, crèmes, plasters, suppositories
- Psychological and lifestyle counseling
- Behavioral therapy and counseling
- Homeopathic medicine: the use of highly diluted quantities of naturally-occurring plants, animals, and minerals to gently stimulate the body’s healing responses
- Lifestyle and hygiene counseling: diet therapy, exercise, sleep, stress management, etc.
- Prescription of over-the-counter and pharmaceutical medications
- Hormone replacement: thyroid
- Hydrotherapy
- Other procedures recommended for my or my child’s condition(s)
By signing this form, you consent to the above procedures and treatments, as indicated. You will have the opportunity to discuss with your practitioner(s) the various types of treatments proposed for you or your child’s condition, and the purpose and objectives of these procedures will be explained.
A cure or improvement from treatment is not guaranteed.
POTENTIAL RISKS OF TREATMENT
There are some rare but potential risks to treatment and procedures. Some of these risks include, but are not limited to the following:
- Reactions to prescribed substances (herbs, supplements, homeopathics, medications): allergic reaction, unpleasant side effects, or exacerbation of symptoms
- Inconvenience of lifestyle changes
- Emotional release, emotional distress, healing crisis
- Hydrotherapy: Burns or skin irritation, overheating, contact dermatitis, dizziness. Theoretical risks include: exacerbation of autoimmune reactions, heart failure, or malignant metastases.
- Notice to pregnant women: All female patients must alert their practitioner if they know or suspect that they are pregnant, or if they are nursing a child. Some of the therapies used could present a risk to the mother or baby. This includes calling or messaging their practitioner once you learn you are pregnant, to confirm the therapies you’re using the things previously prescribed are safe to continue taking during pregnancy.
- You are welcome to ask about risks and benefits of proposed treatments at any time. You are also free to withdraw your consent and discontinue participation in treatments at any time.
Note that doing an individualized vaccine schedule may place yourself, your child, or other families at risk of contracting certain infectious diseases, some of which may cause permanent symptoms and/or death.
PRIMARY CARE
Please note that the practitioners at the Peirson Center for Children are not acting as your primary care physician and we require that you have a primary care physician. If you or your child has a serious health problem that requires immediate attention you should call your primary care doctors(s), call 911, or have someone take you or your child to the nearest hospital emergency room. Please note that we do NOT have an after-hours answering service or 24-hour call shifts.
If you notice an adverse effect from one of the components of your health plan, you should discontinue it and contact our office.
TERMINATING CARE
We reserve the right to terminate the doctor/patient relationship at any time for any reason, and are under no obligation to state the reason for discontinuing care.
(II) PRIVACY POLICY AND ACKNOWLEDGMENT
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain privacy rights concerning your healthcare information. Under this law, your healthcare provider generally cannot give your information to your employer, use or share your information for marketing or advertising purposes, or share private notes about your mental health counseling sessions without your written consent. As one of your providers, it is our responsibility to keep your information safe and secure. A record will be kept of the health services provided to you. This record will be kept confidential and will NOT be released to others unless required by law or specifically directed by you or your legal representative.
Your record MAY be shared in the following ways:
- For coordination of care; multiple healthcare providers may be involved in your treatment, directly and indirectly.
- With family, friends, relatives, or others that you specifically identified on this form as having access to your health information or treatment.
- With other clinic members, administrative assistant, or students under their tutelage, who are involved in your child’s treatment. Information will only be shared on a need-to-know basis.
- In other instances as required by law.
- Your provider is also required to report suspected abuse of an elder or child.
ACCESSING YOUR OWN MEDICAL RECORDS
You may look at your child’s health record online or request a copy at any time in writing. You may be charged an administrative fee for printed or faxed copies of your record, and it can take up to 30 days for us to deliver your records. Your health records will be kept for a minimum of 7 years after the date of your last visit.
You have the right to make requests on how and with whom your information is shared.
COMMUNICATIONS
E-MAIL & MESSAGES:
E-mail is not confidential. We therefore allow patients to send secure messages through our secure patient portal. Any messages sent will be added to your patient record. Although creating a portal account is free, please note that there may be a fee for care management done through the portal or by phone outside of an office visit. Messages sent through the portal are not a substitute for care.
We ask that you limit messages you send to your practitioner and contact our office manager for questions regarding your child’s care plan or other aspects of coordinating care for your child.
ON CALL:
Please note that we do NOT have an after-hours answering service or 24-hour call shifts. There is no “on call.”
TELEMEDICINE & PHONE/WEB APPOINTMENTS:
Telemedicine and Web/Phone Appointments involve electronic communication of your/your child’s personal medical information to a practitioner who may be located in another state or country. We take precautions to ensure your privacy, but do not make any guarantees regarding the HIPAA-compliance of the technology used.
In the absence of in-person visits on a semi-regular basis patients will work with the practitioners at the Peirson Center for Children on a consultant/client context, wherein the practitioners do not prescribe medication, but offer general health “coaching” services.
Phone/web appointments are not a substitute for in-person care. If you anticipate primarily engaging the Peirson Center for Children through such remote appointment types, then please also establish care with a provider local to you, who you can see in person.
LIST SERV:
ALL active patients will be automatically added to our listserv. We reserve the right to send e-mails very infrequently with important clinic updates (such as holiday closures and policy changes). We ask that all active patients stay subscribed to this listserv, so that you can receive important information.
RECORDINGS:
Please do not make video or audio recordings of your visits in part or whole without explicitly obtaining the written consent of your practitioner at each visit. Your provider has the right to refuse recordings. If you do record sessions (with permission) in part or whole, you agree to use said recordings for personal use only. They may not be shared with others, posted to the internet, quoted in publication, or used in litigation against your practitioner.
(III) FINANCIAL POLICY
PAYMENT
Payment for all office visits (whether or not you have insurance) is due at the time of scheduling your child’s appointment.
HEALTH INSURANCE
The practitioners at the Peirson Center for Children are not currently recognized as in-network providers under any insurance plans and do not plan to ever be. We do not guarantee any reimbursement or coverage from your insurance provider. Most insurance plans do not reimburse for telephone or telemedical appointments.
At your request we can send you a superbill for your appointment that you can submit to your insurance company for potential reimbursement.
MEDICAID and MEDICARE, TRICARE, AND V.A. (MILITARY)
Please note that state or federal programs like Medicaid, Medicare, and Tri-Care neither cover nor encourage services provided by an out of network provider. They likewise will not pay for lab work ordered by an out of network provider. By becoming a patient at this clinic, you agree NOT to submit superbills or receipts to your state or federal insurance company for services provided at this clinic. (Doing so could get your health insurance suspended.) Being a patient here means working entirely out of the Medicaid/Medicare/Tri-Care system. You will be responsible for all expenses incurred out of pocket. You may be able to get these services covered by your insurance if you see another doctor or clinic; call Medicaid/Medicare/TriCare for information on how to find a provider covered by your plan.
PHONE CALLS AND ELECTRONIC MESSAGES
Simple questions (clarification of supplement dosing, etc.) will be addressed free of charge. Issues managed by phone or through portal message that include either a new complaint, request for a new prescription, changes to a treatment plan, management of a new symptom, or any matter that takes more than a minute of the practitioner’s or staff’s time will incur a fee.
MISSED APPOINTMENTS AND LATE CANCELLATIONS
For new patient visits: $50 will be charged for missed appointments or cancellations made with less than 24 hours’ notice. This fee must be paid whether you reschedule or not.
Follow up visits: You will be charged a $20 fee for any missed appointments or cancellations made with less than 24 hours’ notice.
LATE ARRIVALS
We understand that sometimes patients arrive late for appointments due to unforeseen circumstances. As a courtesy to other patients and to your practitioner, we must nevertheless end your appointment at the scheduled time if you arrive late. (For example, If your appointment was scheduled for 1-1:30 pm and you arrive at 1:10, the visit will still end at 1:30 pm). You will still be charged for a full visit, and may be required to make another appointment to finish whatever wasn’t covered in your truncated session.
If you are more than 15 minutes late for your appointment, we reserve the right to cancel your appointment and send a $20 no-show fee invoice ($50 for new patient visits) .
We reserve the right to dismiss from the practice patients who no show or late cancel more than three times, even if the appropriate fees are paid.
SUPPLEMENTS
Your provider may prescribe medications, supplements, botanicals, homeopathics, and other products that may be purchased through our online shop, or elsewhere.
Most insurance companies do not cover the natural pharmacy items we prescribe and dispense, though some FSA and HSA accounts will. We do not guarantee coverage.
BLOOD TESTS AND LABORATORY TESTS
Your provider may order laboratory testing (blood, urine, stool tests, etc) as indicated. We do not guarantee that your insurance will cover these tests in part or whole. Checking coverage is the patient’s responsibility. Call your insurance company for more information.