Dear Patient:

Welcome and thank you for choosing Synergistiq Integrative Health (SIH) . Our goal is to treat the whole person using the best of conventional and natural medicine and to guide you towards optimal health. We strive to provide our finest care and services in a professional, warm and supportive environment. We look forward to meeting with you and being able to provide the chance to “create a healthier and happier version of your existence.”

In order to maximize your time with our physician, please fill out all forms completely and bring them with you. This is invaluable information for the physician. Please be sure to arrive at least 20 minutes prior to your appointment time to complete the registration process. This will enable you to get your full scheduled time with the physician.

If you have medical records that you want the physician to review, make copies for yourself and another set for our office to keep in your chart. They will not be returned to you. Please mail us copies of your records. Do not have extensive records faxed, as they are difficult to read.

Phone: 727.754.2936

Fax: 727.754.2937

Address: 3165 N.McMullen Booth Rd, Suite D-2, Clearwater, FL, 33761-2020 I have read, understand and agree to the following. Please initial in each space provided below.

CONSENT FOR TREATMENT, FINANCIAL POLICY AUTHORIZATION & ACKNOWLEDGEMENTS

AUTHORIZATION OF TREATMENT

, hereby authorize medical treatment of myself or my minor child by the physician and staff at SIH.

NOTICE AS TO NATURE OF SERVICES:

Some of the characteristic qualities of medicine that are used in this practice include the following:

A person’s lifestyle including his or her diet, exercise patterns, sleep habits and stresses are believed to be directly related to the development and maintenance of illness. SIH will evaluate these factors and seek to help the patient give up negative life style patterns and establish more positive ones regardless of age or type of medical problem.

Although prescription and over-the-counter medications are used when the physician believes it is necessary, an attempt is first made to use products that are natural to the body. These include nutritional supplements such as vitamins, minerals, enzymes, amino acids, essential fatty acids and herbs.

In addition to recommending that a patient take nutritional supplements by mouth, it is sometimes recommended that a patient receive a series of injections either intravenously or by intramuscular injection. Some of the reasons for recommending this procedure include the assurance that the particular substance gets into the body (which may not happen when the supplement is taken orally and the patient has absorption problems), and achieving high concentration of the substances in the bloodstream, which may be difficult if the substance is taken by mouth.

SIH feels that environmental factors may play a major role in health and disease. Some of the diseases of unknown cause maybe triggered or perpetuated by common environmental substances, many of which are man-made. Individuals may vary greatly in their susceptibility to various substances, so that one individual may be made deathly ill by an exposure to a substance while another is not at all affected. SIH will attempt to identify offending substances and help patients to detoxify from past exposures that are affecting them.

Detoxification diets, elimination diets and lifestyle changes may be recommended and individualized for each patient based upon their lab results and workup and any other pertinent information.

Because SIH looks for imbalances in the body and trends that if not addressed may result in illness, tests are sometimes ordered that may be considered by consensus of “mainstream” medicine as either unnecessary or of no value. These may include tests for nutritional status, vitamins, minerals, hormones, heavy metals, chronic viruses or bacteria, genetic phenotypes, food allergies.

SIH very much believes in persons being fully involved in their own health care and encourages questions, exploration and participation in decisions surrounding their treatment. Consultations are encouraged with consensus of “mainstream” medicine practitioners and use of any other means that a person feels may help guide him or her about their health issues.

Exercise and fitness are extremely important in maintaining health and promoting wellness. Exercise plans may be recommended and individualized for each patient.

SIH believes that true healing and the path to better health and wellness occurs with a strong and synergistic mind, body, & spirit connection. Services such as yoga, acupuncture, emotional therapy, massage, reiki, etc may be recommended.

I understand that the SIH physician, Dr. Verma, will not be acting as my PCP. As such, emergency services are not offered. I understand that even though Dr. Verma may address issues affecting my general health, the practice is focused on an integrative holistic and complementary approach and it is in my best interest to have and maintain my own PCP to ensure that I am fully appraised of all available conventional means to address any medical conditions that I may have.

This is also important because these practices are exclusively office-based and are not affiliated with a hospital. If I become so ill that I require hospitalization, it is vital that I have a primary care physician with hospital admitting privileges familiar with my health problems and history. I understand that in addition to a primary care physician, it may be in my best interest to have appropriate specialists, such as a cardiologist if I have cardiac problems or a pediatrician if I am seeking treatment for my children.

I also understand that it is my responsibility to inform SIH of whom my primary care physician and specialists are, to let my physician know of any diagnoses I have received, and of any treatments I have had or am now undergoing for current conditions, and that I should keep my physicians and any practitioners I see informed on an ongoing basis. I also understand that it is very important to let my primary care physician know about any treatments performed at SIH in order to properly and safely coordinate my care.

NO GUARANTEES: I understand that SIH does not make any representations, claims or guarantees that I will be helped with my medical problems or conditions by undergoing treatment at SIH. However, SIH will do their best to help me accomplish my healthcare and wellness goals.

REVOCATION OF AUTHORIZATIONS: These authorizations will remain active unless revoked by me in writing at any time. Such revocation will not affect my financial responsibility to pay for services rendered.

NUTRITIONAL SUPPLEMENTS: I understand that SIH makes nutritional supplements and other recommended products available. Many of these products are not available through retail outlets or the quality is superior to retail brands. These are provided for the convenience of patients. I am in no way obligated to purchase these products from this office, But I do understand that SIH recommends certain nutritional supplements with my best interest in mind.

NOTICE TO MEDICARE PATIENTS: Dr. Verma has opted entirely out of the Medicare program, which means that Medicare will not cover any services or procedures performed at SIH. I understand that I will not be able to submit any claims to Medicare and that if I have a secondary insurance carrier, that carrier may or may not choose to reimburse claims. I understand that I will need to sign a contract (Medicare Private Contract Agreement) agreeing not to submit to Medicare, that Medicare limiting fees do not apply, and that I will be financially responsible for any services received. I understand that Medicare will not be reviewing any claims, and that an opinion by Medicare that a service is not medically necessary in their view of care would not discharge my responsibility for payment of paid service(s).

INSURANCE CLAIM MANAGEMENT: SIH does not participate with any insurance company. A receipt and an encounter form will be provided to me at the time of visit to submit to my insurance company on my own. SIH does not prepare or submit insurance claim forms. My treating practitioner will not respond to insurance requests for information, and is not obligated to take action on my behalf against an insurance carrier for collecting or negotiating my insurance claim.

I am responsible for the payment of services provided by SIH in full at the time of service without regard to insurance coverage. I am entitled to know the cost of all services and procedures in advance and I will ask if they are not told to me.

FINANCIAL INSURANCE RESPONSIBILITY FOR ALL SERVICES: I understand and agree to the following policies regarding financial and insurance responsibilities. Payment is required in full at each visit. Synergistiq Integrative Health does not accept assignment. I am responsible for charges incurred for all treatment rendered. Differences between integrative and conventional medicine can lead to differences in views about medical necessity. I agree that I am responsible for any payments for services my insurance carrier determines, either now or at a later date, to be unreasonable or not medically necessary. I understand my responsibility to pay includes fees for laboratory and/or other clinical diagnostic testing and/or services requested by my treatment practitioner. SIH will not be obligated to take action on my behalf against an insurance carrier for collecting or negotiating my insurance claim. I also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for SIH to take action to secure payment of an outstanding balance owed. Charges are based on time spent in consultation with the physician and appropriate services rendered.

The initial office cost is $450 for general consult and $400 for medical cannabis consult.

Initial follow up is $395 and any follow-ups thereafter can be between $125 to $200 depending on time and complexity and nature of the visit.

Charges regarding the use of the CVAC pod and InBody 570 scan and IV therapies will be provided to me when I schedule the appointment for that particular service.

Full payment is expected at the time of services rendered.

Any and all past due patient balances will be collected before my appointment.

In addition to the fee for the office visit, the cost for lab work or other specialized testing or sales of supplements deemed appropriate to my case will be applied to my balance.

Questions are always welcome. Most of the labs and testing ordered are more specialized. The discussion of these labs and test results are usually in-depth and lengthy. Therefore a follow-up appointment is always scheduled 2-4 weeks after the initial visit. If an office visit is not possible, a telephone appointment may be scheduled, which will be billed in a manner similar to a followup visit. Based on the complexity of presentation, we may often recommend close monitoring within the first 3-6 months of treatment in order to tailor the program as we progress towards wellness.

SIH is committed to providing the best treatment for patients. All appointments are considered confirmed at the time they are made. I will receive one courtesy call as a reminder of the appointment. Because a substantial amount of time has been set-aside for me, I will be charged a $50.00 fee for a missed new appointment and $35.00 for follow-up appointments. I understand that I need to call the office 24 hours in advance if I cannot keep the appointment in order to avoid this charge.

I certify that the information I provide to my practitioners and my insurance company is correct. I certify that I am here to receive medical care and for no other purpose. I do not represent any third party. I have read, understood and agree to the foregoing. I understand that I have the right to review this consent with a lawyer if I choose before accepting any medical services from Synergistiq Integrative Health.

I have executed this consent freely and willingly understand its provisions. I recognize that SIH will rely upon my signing of this document in accepting me as a patient. I acknowledge receipt of a copy of this consent if I have requested it.

I do hereby acknowledge that by signing this statement of understanding that I acknowledge and understand that some, and perhaps all, of the medical, preventative, nutritional, and diagnostic services provided at SIH on or after the date of my signing this statement may be innovative, non-traditional or unconventional. (Definition: services that are not necessarily recognized by traditional medicine, some physicians, some 3rd party purveyors of the AMA, as acceptable testing/evaluation techniques and/or medical and nutritional recommendations or therapies). I also understand that these unconventional services may be viewed by 3rd party insurance purveyors as non-covered services, in that they might be considered unreasonable or unnecessary under any medical insurance program. I also realize that my insurance coverage may not pay for such uncovered services and that I will be personally responsible for payment to SIH. I understand that I will pay all costs including reasonable attorney fees, should that become necessary. I understand that all outstanding balances bear interest at the maximum rate allowed by law.

I understand that my signature is consent for any and all treatments offered and given to me or my minor child at SIH and that I may not be required to sign individual consent forms for treatments received at SIH.

Please initial each space

Because a substantial amount of time has been set aside for me, I will be charged a $50.00 fee for a missed initial new appointment and a $35.00 fee for any follow up visits. I understand that I need to call the office at least 24 hours in advance if I cannot keep the appointment in order to avoid this charge.

I understand that I am providing SIH with my credit card information below that will be kept on file in order to secure my appointment time. I also agree that SIH has my authorization to charge my card in the event that I do not give them adequate notice to cancel or reschedule my appointment as per office policy. I understand that my credit card information will only be used as stated above.

Credit Card Information:

NEW PATIENT APPOINTMENTS:

• Please allow approximately 1.5 hours for this appointment. During your first visit we will be conducting a detailed consultation and evaluation of your medical concerns and a physical examination if deemed necessary.
• Please arrive at least 20 minutes prior to your first appointment to ensure all paperwork is completed.
• Because of the length of time we have reserved for you, please call the office at least 24 hours in advance to reschedule or cancel an appointment. This would enable another patient to be seen. SIH does not double book appointments.
• Since we are non-participating providers with all insurance companies, we require all of our patients to maintain a relationship with a primary care physician.
• Please review the policies regarding missed appointments without notice that were previously discussed.

• Please be sure to arrive 15 minutes before your scheduled appointment. This will enable us to sign you in, perform vitals and ensure you get your allotted time with the doctor.
•  In order to help you on your path to wellness, it may be recommended for you to see a nutritionist. This is an invaluable visit which will help you make positive lifestyle changes and understand how your supplement regimen and food choices have a great impact on your health and well being. Making these changes can be difficult and challenging at first and this appointment will help you achieve your goals.
• Follow up appointments are scheduled 3-4 weeks after the first appointment. This is the time to discuss test results and to discuss your treatment plan and make any changes if necessary. The 3 visit process (i.e. the first initial visit, the nutritional consult, and the follow up visit) is the best way to get you on track with your protocol and to making a real difference in your health.
• Because of the complexity of most cases, treatment protocols may need frequent adjustments in the beginning. Therefore we may require monthly office visits in the first 4-6 months or more often as deemed necessary by your practitioner in order to facilitate wellness.
• No results can be discussed over the phone due to the in-depth information that will need to be discussed. A follow-up appointment or phone appointment will need to be scheduled.

• If you arrive more than 10 minutes after your scheduled appointment, it may be necessary to reschedule and this will be at the physician’s discretion.
• If you choose to keep your appointment, your office visit may be shortened.
• If you choose to reschedule, the missed appointment fee may apply, so please call if you are running late.

• Because of HIPAA regulations, we communicate only through our office telephones. We cannot communicate lab results through email. Please be sure to call our office with any questions.
• During office hours, please call the office and leave a message. Someone from the office will get back to you. • On weekends and after hours, please call the office and leave a message and an attempt will be made to return your call within 24 hours.
• Phone calls pertaining directly to your recent visit which require 1-2 minutes will be answered. Please understand that often the schedule is full and non-emergency calls will be returned within 24 hours or the next business day. More complex discussions will require a follow up appointment. If needed, a phone appointment will be scheduled.

• At the time of your office visit, the practitioners will be giving you prescriptions with the appropriate number of refills to last you till your next follow up visit. Please make sure you have all the prescriptions you need before you leave the office.
• Failure to make and keep scheduled appointments will make it difficult to continue your care and will result in having refills denied.
• Refills of prescriptive medications require at least a 48 hour notification.
• I.V. prescriptions for nutrition have a 3 month expiration after which an office visit is required for evaluation and blood work. If you have not been seen in our office within 3 months, prescriptions will not be refilled without an office visit for both prescriptions and I.V. treatments.

For IV therapy patients, the infusion bags are prepared the morning of your appointment. If you are unable to make your appointment for IV therapy, please call at least 24 hours in advance to cancel so as not to incur a charge of $50 due to a wasted bag.

• It is imperative that all lab work that has been agreed upon to be performed by you and the practitioner be completed within the time frame discussed. This ensures that the results are available for discussion during your next scheduled appointment and eliminates the need to reschedule as it may become difficult to accommodate your schedule needs.
• Because of the wide variety of testing and companies we use, the receipt of them can vary from several days to several weeks. Rest assured, once completed results are received, we will confirm your next appointment that should already have been scheduled at your last visit. Therefore it is not necessary to call the office to ascertain the receipt of tests performed. We routinely do not call you when they arrive unless the practitioners need to speak to you immediately. • Allow at least two full weeks for the results to arrive at SIH.
• In order to ensure the best understanding of your lab results and to answer all of your questions, a follow-up appointment is required. Results will not be discussed over the phone.
• Our support staff is not allowed to discuss results over the phone.
• We ask that you wait until your appointment to request a copy of your labs to avoid any confusion about the results.

• Fasting blood work requires that you have nothing by mouth after 10:00 PM besides water the night before. • (A small amount of water or coffee with no cream or sugar is allowed).
• Use of your prescription medications will not affect the test. Blood should be drawn by 8:00 AM to obtain the correct levels or as otherwise directed by the physician.
• When using an outside lab, arrive at the lab no later than 7:30 AM to allow for registration. Please make sure an appointment has been scheduled at the lab if needed. Bring your lab order and any additional testing kits with you to the laboratory.

• Nutritional supplements can be refilled by calling our office prior to pick up, or can be shipped directly after being ordered through SIH. They can also be ordered online on our website.
• Please allow 3-5 business days from the time you order to the time you receive it.
• There is not a need for an office visit to refill nutritional supplements.
• In most cases you will need to continue on your current regimen until your next visit.
• Only unopened supplements will be refunded at full price within 30 days of purchase.
• Supplements that are open and then stopped either by your physician or yourself for any reason cannot be returned.

• We are non-participating providers for all insurance companies including Medicare.
• We do not bill Medicare or any other insurance company.
• Because we have opted out of the Medicare program, Medicare does not allow reimbursement for any services rendered by our office.
• The only exception is certain specialized labs where the lab will bill Medicare directly.
• At the time of your visit, we will give you a receipt and an encounter form with appropriate codes which enables you to submit your claim to your insurance company directly. Please be sure to make additional copies for your records. Most insurance companies have a claim form on their website which you can download to attach to your receipt and encounter in order to seek reimbursement.
• Your insurance coverage is a contract between you and your insurance company. For this reason, we do not respond to requests or inquiries from insurance companies for office notes, lab results, and letters of medical necessity or claim appeals. Since we are non-participating providers with all insurance companies, our involvement generally results in denials and is therefore not beneficial in obtaining approval.

• A signed release is required before any information in your chart can be mailed/faxed to you, another.
• physician or third party.
• The cost of handling & copying your medical records for yourself will be a minimum of $10.
• Records are sent to your physician at no charge.
• Copies of your labs are given to you at your follow up visit.
• Additional copies will have to be requested and you may be charged for it.
• If you are having records sent to our office, please have them mailed to our office.
• Faxed copies are difficult to read.