Medical Form

Medical Patient Form Information

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Text messages (yes/No)
Marital status
I have the following conditions
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LIST OF MEDICATIONS
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PATIENT INFORMED CONSENT(Required)
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Consent to treat minor (yes/no)

Consent for Use and Disclosure of Protected Health Information

With my consent, Hood health and Wellness Center, may use and disclose protected health information (PHI) about me to carry out treatments , payments and healthcare options (TPO). Please refer to Hood Health and Wellness Center's Notice of Privacy Practices for a more complete description of such uses and disclosures.

i have the right to review the notices of privacy practices prior to signing this consent. Hood Health and Wellness Center reserves the right to revise its notice of Privacy Practices at any time. A revised copy may be obtained by forwarding a written request to our office at P.O. Box 3004, Flint, TX 75762.

With my consent, Hood Health and Wellness Center may call my home or other designated locations to leave a message on voicemail or in person in references to any item that assists the practice carring out TPO. such as appointment reminders. I have the right to request that Hood Health and Wellness Center restrict how it uses or discloses my PHI to carry out TPO; however, the practice is not required to agree to my requested restriction; but if it does, it is bound by this agreement.

By signing this form, I am consenting to Hood Health andv Wellness Center use and disclosure of my PHI to carry out TPO.
i may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this agreement, Hood Health and Wellness Center may decline to provide my treatment.

PATIENT CONSENT / AUTHORIZATION

I authorize Hood Health and Wellness to leave medical information pertaining to my care by the following methods and will assume responsibility to notify them whenever this information changes.

Please Select YES or NO and list Telephone Numbers

Home Telephone(Answering machine)(Yes/No)
Cell Phone (Yes/No)
Work Telephone (Yes/No)
Email (Yes/ No)

Please list names of people we can discuss your care and records with:

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By using the key below, indicate on the body diagram where you are experiencing ANY of the following symptoms:
N = Numbness B= Burning S= Stabbing T= Tingling A= Dull O= Other
How often do you experience your symptoms?(Required)
Have you experienced any restrictions in your activities of daily living, social or recreational?(Required)
If so, is it:

Financial Policy

Please take a moment to review the financial aspect outlined below related to your treatment so we can direct allof our attention to getting you back to health.

Payment OPtions: Our office accept cash, check, Visa, MasteCard, and Discover. If paying by check, we maintain the option to place a hold on ordering the program until the check has cleared the bank which could take up to 10 business days. financing Options: Our office also offers several different medical financing options including Care Credit- for patients with good to excellent credit and united Credit- for patients with fair to good credit.

Returned checks: A check returned from a financial Institution is subject to a returned check fee. the current fee is $30.00 per return. If Payment of the non-sufficient check is not received within 10 days of notification, the NSF check will be turned over to the Smith County District Attorney's office for collection and/or prosecution . Discount:When you Sign up for a treatment program we MAY also offer a discount based on the payment terms you choose with the largest discount being for those patients that pay in full for their treatment up front utilizing cash or their own personal credit line(not included Care Credit or United Credit). Note that these Discount are based on completing the full treatment prescribed See below for details on payment terms/refunds if treatment is discontinued.

Insurance:Our office does not directly file on insurance for any treatment or programs. we cannot guarantee any reimbursement by your insurance however, upon request; we can provide you with an intemized Statement with the diagnosis and procedure codes for your plan so you may file for any potential reimbursement. Request for an intemized ledger must be made within 1 week of the start of your program and will be fulfilled within 7 business days. Request after that time may take up to three weeks to process:

Payment Terms/ Refunds: The agreed upon treatment program is based on providing you with optimal results aimed at improving your overall health and quality for life. Payment is required prior to your first treatment based on the payment terms agreed upon...

Regenerative Medicine: I understand that any regenerative product(s), services and treatments provided within the regenerative medicine program are non-refundable. I also understand the product will be ordered specifically for my personal treatment plan once full payment for the product is received

Equipment and Orders Agreement: I understand that the equipment and professional protocols (supplements) that I receive are non- refundable. Once the equipment is ordered I understand its is my possession and registered to me

if you should choose to discontinue your program before the length of the treatment is completed and have already paid for your treatment in advance, you may request a refund from us; with the exception of any regenerative medicine, weight loss and home equipment. Refunds request must be submitted in writing to our office within 2 weeks of your last treatment(refunds requests guaranteed). Any refunds will be issued within 30 days of receipt of your written request. Since discount may be provided up front based on full treatment being completed, any refunds will be issued based on calculating FULL RATE for the treatment already received, and there will also be a $250.00 administrative fee that will be deducted when calculating any refunds due. Any difference between the full rate of treatment already received and the upfront payment will be issued via check and malled to the address on the file with our office. All unused treatment are non- transferable and expire 12 months after purchase date.

I have read and understand the practice's financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.