Privacy Policy

HLH Total Wellness LLC Private Practice-Patient Agreement

 

This Private Practice-Patient Agreement ("Agreement") specifies the terms and conditions under which, you, the undersigned patient ("Patient") may voluntarily elect to participate in the healthcare services offered by HLH Total Wellness LLC, a a wellness clinic specializing in weight loss, functional medicine, hormone replacement therapy, telehealth services, IV therapy, lab work, and more ("Practice") as described in Schedule A and summarized as follows:

 

• Practice's comprehensive integrative/Functional Medicine diagnostic routine exam services, provided on a regardless of medical condition or necessity basis, with follow-up routine diagnostic exams as further specified in Schedule A (collectively "Integrative Exams"); and

• An online health data storage and communication facilitation platform plan designed to provide efficient and reliable electronic communication and health data storage support for Integrative Exams and to help patients achieve Integrative Exams-based health goals ("Health Data Services"). Integrative Exams and the Health Data Services described in Schedule A are collectively the "Integrative Exam Services" and Patient and Practice are referred to individually as "Party" or collectively as the "Parties."

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Privacy of Consumer Information

At HLH Total Wellness, your privacy is our priority. We are committed to protecting your personal information and ensuring it remains confidential. No Sharing with Third Parties

HLH Total Wellness does not share consumer information with third parties for marketing purposes. Your data will never be sold, leased, or provided to any external organizations for advertising or promotional activities. The information we collect is used solely to enhance your experience with our services, maintain your records, and communicate with you effectively

 

INTEGRATIVE EXAM SERVICES

Practice makes Integrative Exam Services available to Patient in exchange for Patient's payment of the program subscription fees outlined in Schedule A ("Services Fees*). Services Fees may increase from time to time with Patient's voluntary consent in advance but will apply to renewal terms. If Services Fees increase, Practice will notify Patient in writing with the option to consent to the increase.

Practice reserves the right to update the Integrative Exam Services in Schedule A from time to time, and if it does, Practice will notify Patient of any changes within thirty (30) days after a change is made and shall secure Patient's voluntary consent to any such modification of Integrative Exam Services or Services Fees. Integrative Exam Services exceed or are beyond those covered by Patient's Medicare, Medicaid, or private insurance plan (collectively "Plan"). Because Integrative Exam Services include integrative/Functional Medicine alter-natives, Patient provides informed consent to such services as documented in the attached Schedule B.

PAYMENT OPTIONS

Patients may pay the Services Fees with a credit card either monthly, bi-annually, or annually. Services are designed to allow Patient to pay Services Fees with health saving account ("HSA*) funds or with flexible spending account ("ESA*) or health reimbursement account ("HRA") funds, but Patient must confirm eligibility with Patient's tax expert or FSA/HRA plan coordinator as Practice cannot guarantee eligibility due to variable factors applicable to each Patient. Service 

Fees cover the availability of the Integrative Exam Services selected by and subscribed to by Patient for a period of one (1) year.

 

RENEWALS AND TERMINATION

This Agreement will automatically renew one (1) year from the date of this Agreement unless the Practice receives written notice from Patient to terminate this Agreement thirty (30) days before Patient's renewal date or Practice terminates the Agreement. Failure to pay the renewal Services Fees before the expiration of the permissions services

 

RENEWALS AND TERMINATION

This Agreement will automatically renew one (1) year from the date of this Agreement unless the Practice receives written notice from Patient to terminate this Agreement thirty (30) days before Patient's renewal date or Practice terminates the Agreement. Failure to pay the renewal Services Fees before the expiration of the prior period may result in termination of this Agreement. The Practice is permitted to terminate this Agreement with thirty (30 days prior written notice to Patient, in which case Patient will receive a prorated refund of the Services Fees but the delivery of any Integrative Exams renders Services Fees substantially earned by Practice.

 

HEALTH CARE SERVICES EXCLUDED FROM SERVICES FEES

Services Fees cover only the availability of Integrative Exam Services subscribed to by Patient as described in this Agreement and Schedule A. If the Practice provides services other than the Integrative Exam Services described in this Agreement and listed in Schedule A, the Parties may agree upon any additional charges, if any, to the extent the Patient's Plan does not cover those services. Patient acknowledges that either Patient or Patient's Plan will be responsible for such additional charges for services outside of Services. Any charges to the Patient for any services outside of Plan coverage and Integrative Exam Services will be at Practice's usual. reasonable and customary rates with Patient's advance consent. Plan co-payments, deductibles, and the costs for all services other than Integrative Exam Services are the sole responsibility of the Patient.

ELECTRONIC COMMUNICATIONS

If Patient wishes to communicate through electronic mediums with Practice, Patient needs to be aware that electronic communications may not always constitute a secure medium for sending or receiving sensitive personal health information. Practice will take reasonable steps to keep Patient's communications confidential and secure and comply with applicable health data privacy obligations under applicable laws. Please refer to Practice's separate Electronic Communications Agreement for further applicable details in this regard, which is integrated herein by this reference.

 

APPOINTMENTS AND SCHEDULING

Appointments with the Practice are scheduled through the Practice office to ensure ample time is given to each Patient. If Patient has an urgent concern, Patient shall call the Practice office and Patient will be given an appointment that will accommodate the urgency. Walk-ins are not conducive to the thoughtfully planned schedule, so we advise patients to schedule appointments in advance.

 

MEDICARE/PRIVATE INSURANCE

HLH Total Wellness does not accept insurance.

 

VACATIONS AND ILLNESS FOR PRACTICE PHYSICIANS

Patients acknowledge possible unavailability of healthcare professionals due to vacations, illness, or technical issues. Emergency care should be sought independently.

 

COMPLIANCE WITH LAW

In establishing the Integrative Exam Services programs, Practice intends to do so in compliance with all applicable laws. This Agreement shall be governed by and construed in accordance with the laws of the state in which Practice is licensed and practicing, without application of choice-of-law principles.

 

PRACTICE IS NOT AN INSURER

Practice is not an insurance company and is not promising or delivering unlimited care for Services Fees. The Practice presumes that a Patient is either eligible for Medicare, or otherwise has a private Plan that provides health care coverage for essential healthcare services not covered by the Services Fees.

AGREEMENT ASSIGNMENT AND MODIFICATIONS

Patients may not assign this Agreement. This Agreement replaces and supersedes all prior agreements of any kind, oral or in writing, between Patient and Practice. This Agreement may not be modified absent a writing signed by Patient and an authorized representative of Practice.

PATIENT ACKNOWLEDGES THAT HE/SHE HAS CAREFULLY READ THIS AGREEMENT, WAS AFFORDED SUFFICIENT OPPORTUNITY TO CONSULT WITH LEGAL COUNSEL OF HIS/HER CHOICE AND TO ASK QUESTIONS AND RECEIVE SATISFACTORY ANSWERS REGARDING THIS AGREEMENT, UNDERSTANDS HIS/HER RESPECTIVE RIGHTS AND OBLIGATIONS UNDER THIS AGREEMENT, AND SIGNS THIS AGREEMENT OF HIS/HER OWN FREE WILL AND VOLITION.

 

Schedule A

Integrative exam services and service fees

Integrative exams

Practice will provide patients the availability of one (1) initial intake comprehensive root cause of dis-ease/Functional Medicine Integrative Exam with laboratory testing, and follow-up annual Integrative Exams intended to establish hormone optimization and help guide health goals identified in the initial intake Integrative Exam. Integrative Exams shall integrate the following health principles and goals:

• • Optimizing health

• • Improving energy and focus

• • Preventing when possible age-related diseases and decline

• • Restoring balance

• • Addressing sleep, exercise, and nutrition for best overall wellness

• • Exploring the mind-body connection and improving resilience to stress

• • Slowing down to the extent feasible the aging process and maintaining vitality

• • Improving overall health awareness and equipping patients with enhanced health education

• • Better managing chronic conditions susceptible to behavior modification and education improvements.

The Health Data Services ("Health Data Services") are designed to assist with storing Patient's Integrative Exams health data and to improve Patient's Integrative Exam-based electronic communication connection with Practice to facilitate Integrative Exams health goals and education as outlined above. Practice's Health Data Services will keep Patient's medical information electronically stored so that, upon request of Practice, information can be retrieved and furnished to further support the Integrative Exams-related Services. The Health Data Services will facilitate and empower Patients to interact with Practice via electronic communication regarding Practice's Services.

 

ADDITIONAL TERMS:

Due to the smaller patient panel size of the Practice, Practice anticipates Patient will enjoy little or no wait times for exams scheduling and related electronic Practice communications. Practice's healthcare professionals will also have the extended time and availability to provide unhurried visits to support ongoing health guidance and education. Due to the Health Data Services, if applicable, Patients will enjoy direct and immediate communication with Practice using an electronic communications portal designed to achieve HIPAA/privacy compliance.

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Medicare/Medicaid Eligible Patients

If you are eligible for Medicare or Medicaid, please be aware that HLH Total Wellness does not provide any services that can be billed to Medicare, Medicaid, or any private insurance plans, even if those services might otherwise be covered elsewhere. This includes, but is not limited to:

• Medicare-covered wellness checkups, annual wellness visits, chronic care management, remote patient monitoring, telehealth services, or other reimbursable services.

• Any covered services by Medicare, Medicaid, or other insurance plans.

 

Private Fee Structure

All services offered by HLH Total Wellness are provided as private fee services. The fees for our services are not reimbursable by Medicare, Medicaid, or private insurance, and patients agree not to submit claims to any insurance plan for any fees paid. By choosing our clinic, patients acknowledge that:

• Payments made for our services are private and cannot be submitted for reimbursement by any insurance plan.

• We do not participate in any insurance networks and will not coordinate billing or payments with any third-party payers.

SCHEDULE B CONSENT FOR INTEGRATIVE SERVICES

Integrative Exams Services and related supportive services may include, at the election of Patient, additional integrative services that are outside of and different from strictly allopathic healthcare services. Integrative services may include: bioidentical hormone replacement therapy, acupuncture, Chinese medicine, source acupoint essential oil therapy, herbal medicine, chelation, IV treatments, cupping, low-impact yoga, Reiki, hypnotherapy, healing touch, massage, aromatherapy, relaxation/stress/guided imagery/self-hypnosis/ mindfulness education, meditation, energy therapy, and other similar services outside the mainstream of allopathic care ("Integrative Services"). Patient has reviewed and understands all of the following with respect to such integrative services.

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GENERAL STATEMENTS ABOUT INTEGRATIVE SERVICES:

Integrative Services may assist with the restoration of health and optimal functional capacity, relief of pain and symptoms, injury and disease recovery, and prevention or reversal of disease or disease progression. But this is not guaranteed, as Patient's health outcomes depend on a wide range of variable factors. No healthcare services (including Integrative Services) are guaranteed to provide positive results. In fact, Integrative Services pose risks and may cause potential complications. Practice's healthcare professional has explained those risks and potential complications, and this Schedule B is intended to confirm Patient's acknowledgment of those explanations and to confirm Patient's informed consent to Integrative Services Patient elects to receive.  Practice has not promised or guaranteed any specific benefits from the administration of Integrative Services and has made no warranty or guarantee about the results 

of any such treatment. Patient has weighed the benefits of, and alternatives to, Integrative Services. Practice 's healthcare professional cannot know or anticipate and explain every possible risk or complication that may connect to Integrative Services. Patient willingly and voluntarily consents to any Integrative Services Patient elects to receive from Practice with an 

understanding there is no guarantee of benefits, and there is the potential for side effects and negative outcomes.  There are alternatives to Integrative Services. Traditional allopathic diagnosis and treatment of detected illness constitutes standard healthcare. Lifestyle/behavior changes, including beneficial changes to nutrition, exercise, improved mental health/wellness support, cessation of smoking, limiting, or reducing alcohol or recreational drug intake, ensuring adequate sleep/rest, have all also proven to help reduce risk of illness and increase wellbeing. Adopting some or all of these lifestyle changes, in tandem with traditional allopathic diagnosis and treatment of illness, can provide patients important and substantiated health benefits. Health coaches routinely provide support with lifestyle change efforts toward improved health outcomes. Licensed healthcare professionals can assist with health conditions that are directly and obviously connected to lifestyle issues and may provide referrals to a wide variety of professionals who can assist nutritionists, dietitians, physical therapists, etc. 

In other words, there are variable alternatives to electing to receive integrative services. new permissions provide referrals to a wide variety of professionals who can assist (nutritionists, dietitians, 

physical therapists, etc.). In other words, there are viable alternatives to electing to receive Integrative Services.

 

HRT BACKGROUND:

Practice may prescribe some of the bio-identical hormone preparations for patients that pharmacy compounding laws regulate. These laws follow the Pharmacy Compounding Accreditation Board (PCAB) guidelines.

The use of this HRT therapy as it relates to Patient's diagnosis, while common in alternative practices, may be debated in the traditional medical community. Patient has the right, as a patient, to be informed abc Patient's condition and the recommended conventional, integrative, complementary, alternative, non-conventional, or non-standard procedures to be used so that Patient makes an informed decision whether or not undergo the HRT treatment with an appreciation of the risks, hazards, and alternatives. This disclosure is not meant to scare or alarm Patient, but to simply inform Patient's consent to HRT treatment. HLH Total wellness wants Patient to have the information needed to give or withhold Patient's consent to HRT treatment.

NOTICE: Refusal to consent to HRT treatment as an innovative, integrative, complementary, or non-standard procedure shall not affect Patient's right to receive ongoing or future Practice care or treatment.

 

HRT THERAPEUTIC BASIS:

Many individuals have inadequate hormone levels despite technically "normal" blood tests. Some individuals suffering symptoms related to menopause or andropause or inability to lose weight may also benefit from hormone therapies. Bio-identical HRT can be used to augment hormone levels in many conditions where diminished hormone levels are evident. These HRTs 

can optimize hormone levels in the blood, helping to reduce symptoms associated with low levels of these hormones.

 

-Estrogen therapy, while not always effective, can maintain vaginal and urethral function and slow the progression of osteoporosis. It may also improve sleep, decrease hot flashes and night sweats, decrease pain and perhaps improve cognitive function, and improve libido and overall well-being. This therapy may contain on. or any combination of these medications: estriol, estradiol, and/or estrone.

-Progesterone hormone replacement therapy can, although not always, offer protection from endometrial cancers, treatment of irregular menstruation, and other low progesterone conditions. It also can sometimes improve sleep quality and decrease anxiety. For males, low dose progesterone therapy along with testosterone therapy might maximize the hormone ratios while reducing side effects.

 

Testosterone replacement therapy is used to treat symptoms or lab tests suggesting suboptimal hormone levels as determined by Patient's Provider. Low testosterone is linked to elevated cholesterol, high blood pres-sure, diabetes, and prostate problems. Other low testosterone symptoms include excessive fatigue, abdominal weight gain, irritability and decreased sexual drive and function. Again, while hormone therapies are not always effective or helpful, and may cause some undesirable side effects, hormone therapies also may be very useful for patients who desire hormone therapeutic support.

 

HRT POTENTIAL RISKS:

Practice cannot guarantee safety of any hormone therapy during pregnancy. Notify Practice's healthcare professional if Patient is pregnant, suspect that Patient is pregnant, or are planning to become pregnant during this therapy.

 

Estrogen Therapy: Bio-identical estrogens are available in various forms including oral capsules, troches, patches, pellets, and topical creams. Adverse reactions may include bloating, breakthrough bleeding, breast swelling and tenderness, fluid retention, weight gain, liver cysts, death (e.g. from blood clots or cancer) and mood swings. High potency conjugated estrogens (e.g. Premarin) have been linked to an increased risk of breast cancer and blood clots (the latter especially in smokers). Estriol may carry a lower risk of breast cancer and may even protect 

against breast cancer. Nonetheless, the whole area of estrogen replacement is undergoing further evaluation. Do not take estrogen if Patient has breast cancer.

 

Progesterone Therapy: Bio-identical progesterone is available in various forms including oral capsules, troches, vaginal or rectal suppositories, and topical creams or gels. Progesterone therapy may be sedating, so it is recommended to coordinate dosing with sleep cycle. Adverse 

reactions may include bloating, breakthrough bleeding, missed menstrual cycles, breast swelling and tenderness, fluid retention, weight gain, sedation, and depression.

Testosterone Therapy: Bio-identical testosterone therapy is available in various forms including sublingual drops, troches, topical creams, pellets, and injection. Side effects include acne, chronic priapism (persistent, abnormal erection of the penis), change in libido, erythrocytosis, angina or heart attacks, hirsutism (facial hair growth) and scalp hair loss, clitoral engorgement, voice changes, or water retention. In men, it may also cause testicular atrophy and infertility. Because it may improve insulin resistance in males, diabetics who use insulin should monitor glucose levels closely, as diabetics may need less insulin. Patient must check with Patient's physician before adjusting Patient's dose of insulin. If using a formulation of testosterone that is applied to the skin, a local irritation may occur.  Although many studies have shown the use of bio-identical hormone replacement therapy to be safer than synthetic hormone replacement therapy, the risk of cancer-related side effects is still possible. In fact, some physicians do not agree with using bio-identical hormones.

 

ALTERNATIVES TO HORMONE THERAPIES:

Hormone therapies are applying hormone balancing and treatments to different conditions, some of which may not qualify as an "illness" requiring "treatment under traditional medical thinking. In other words, traditional medical thinking does not identify feeling better, or having more energy or vitality, as medically necessary for patients or as justification for medical intervention.

An endocrinologist is a healthcare professional licensed and trained specifically to address issues involving hormone health. Their approach is more traditional in that their training and protocol is to only prescribe hormone therapy if medically indicated for a specific diagnosed disease state. For example, a male experiencing the side effects of having low testosterone may not qualify under an endocrinologist's treatment algorithm for testosterone supplementation. Females experiencing the effects of perimenopause or postmenopause may be suffering from those side effects, yet not meet traditional medical criteria for hormone treatment. Seeking non-integrative healthcare from professionals other than Patient's Provider who is an integrative healthcare professional trained to implement hormone therapies is an alternative Patient should pursue if Patient feels uncomfortable about the side effects of hormone therapies or wish to adopt a more conservative approach to hormone heath. 

 

STATEMENT OF PATIENT ABOUT HRT:

Patient agrees to proceed with the HRT hormone health treatment and to comply with recommended dosages. Patient agrees to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of all aforementioned hormone levels or other diagnostic testing by a long-term health care provider, Patient's primary care physician, or other specialist.

THYROID HORMONE REPLACEMENT (THR) THERAPY:

Practice may prescribe thyroid replacement hormone (TRH preparations for Patients that pharmacy compounding laws regulate. These laws follow the Pharmacy Compounding Accreditation Board (PCAB) guide-lines. TRH formulations may include synthetic T4, synthetic T3, bioidentical T4, bioidentical T3, sustained release formulations, and T4/T3 combinations derived from porcine thyroid gland (e.g., Armour Thyroid or Nature Throid).

The use of this THR therapy as it relates to Patient's diagnosis, while common in alternative practices, may be debated in the traditional medical community. Patient has the right, as a patient, to be informed about Patient's condition and the recommended conventional, integrative, complementary, alternative, non-conven-tional, or non-standard procedures to be used so that Patient makes an informed decision whether or not to undergo the thyroid hormone replacement treatment with an appreciation of the risks, hazards, and alterna-tives. This disclosure is not meant to scare or alarm Patient, but to simply inform Patient's consent to THR treatment. Practice wants Patient to have the information needed to give or withhold Patient's consent to THR treatment.

 

NOTICE: Refusal to consent to THR treatment as an innovative, integrative, complementary, or non-standard procedure shall not affect Patient's right to receive ongoing or future Practice care or treatment.

 

THR THERAPEUTIC BASIS:

Some patients present with hypothyroidism with the syndrome of thyroid hormone resistance. This is also called Refetoff Syndrome' which is a condition characterized by symptoms of hypothyroidism [which may present with goiter] and elevated serum thyroid hormones but without symptoms of thyrotoxicosis (danger-ously high thyroid hormone levels), due to unresponsiveness of target organs, and "resistance" to thyroid hormones. This is a condition very similar to the phenomenon "insulin resistance" seen in patients with Type

2 Diabetes?. Although uncommon, there are cases in the literature of patients that require very high levels upwards of 1200 mcg of Synthroid or 720 mg (12 grains) of Armour Thyroid per day to achieve the desired effect on end organ tissues.

Further information about "resistance to thyroid hormone" can be found in the following two references and also at the online database pubmed, www.pubmed.com.

1. Refetoff S. Resistance to thyroid hormone: one of several defects causing reduced sensitivity to thyroid hormone. Nat Clin Pract Endocrinol Metab. 2008 Jan; 4)(1):1.

2. Tjorve E, Tjorve KM, Olsen JO, Senum R, Oftebro H. On commonness and rarity of thyroid hormone resistance: a discussion based on mechanisms of reduced sensitivity in peripheral tissues. Med Hypothesis.

207; 69(4):913-21 Epub 2007 Mar 26.

 

STATEMENT OF PATIENT ABOUT THR THERAPY:

If the patient agrees to proceed with the THR treatment, the patient agrees to comply with recommended dosages and follow up. Patients agree to comply with requests for ongoing testing to assure proper monitoring of therapy that may include thyroid hormone and other diagnostic laboratory testing by the patient's provider, Patient's primary care physician, or another specialist.  Specifically, patients will be monitored regularly with periodic physical examinations, electrocardiograms (EKGs), blood tests, and bone density (DEXA) scans. This patient is aware of the potential symptoms and signs of thyrotoxicosis including heart palpitations, a rapid heart rate, anxiety, nervousness, insomnia, etc.

This patient is aware of the potential for heart rhythm abnormalities such as Atrial Fibrillation, and the dangers of it not being recognized in time. Serious complications include a clot forming within the heart or on a heart valve and potentially traveling ("embolizing") to another side, causing a stroke or even death. This patient does know how to measure his or her own pulse rate and to detect an "irregular" rhythm. This patient is aware that high doses of thyroid hormone could result in adverse effects on bone density. The benefits and risks of high dose thyroid hormone therapy are still being studied.

 

Weight Loss Program

 

1. Program Overview:

   - The weight loss program integrates functional medicine, nutritional counseling, exercise recommendations, hormone balancing (if applicable), and behavioral support.

   - It is designed to promote sustainable weight loss and improve overall health.

 

2. Nature of the Program:

   - Involves initial and ongoing assessments including medical history, physical examination, and laboratory tests to evaluate health status and identify any underlying conditions that may impact weight loss.

   - Customized plan including dietary recommendations, exercise regimen, potential use of supplements or medications, and, if indicated, hormone therapy.

 

3. Benefits:

   - Potential benefits include weight loss, improved physical fitness, better management of health conditions related to weight (e.g., diabetes, hypertension), enhanced energy levels, and overall well-being.

 

4. Risks and Side Effects:

   - Possible side effects may include, but are not limited to, temporary fatigue, hunger, mood changes, and gastrointestinal discomfort.

   - Rare risks include nutrient deficiencies, muscle loss, or exacerbation of underlying health issues.

   - Hormone therapy, if used, carries its own set of risks which are detailed separately in Schedule B.

 

5. Patient Responsibilities:

   - Adherence to the prescribed plan including dietary changes, exercise, and medication/supplement regimen.

   - Regular attendance at scheduled appointments for monitoring and support.

   - Prompt communication of any adverse reactions or challenges faced during the program.

 

6. Alternatives:

   - Alternatives to this weight loss program include, but are not limited to, conventional diet and exercise regimens, medically supervised weight loss programs, bariatric surgery, or choosing no intervention.

 

7. Voluntary Participation:

   - Participation in the weight loss program is entirely voluntary.

   - You have the right to withdraw from the program at any time without affecting your future care at the Practice.

 

8. Confidentiality and Data Use:

   - Your health and program data will be treated as confidential, used only for the purpose of providing care and improving program efficacy.

   - Data may be anonymized and used for quality improvement and research within legal and ethical guidelines.

9. Expected Outcomes and No Guarantee:

   - While the Practice aims to support your weight loss goals, there is no guarantee of specific results as individual responses to the program vary.

   - Ongoing adjustments to the plan may be necessary for optimal results.

 

10. Costs and Insurance:

    - Costs associated with the weight loss program are detailed in Schedule A of the Agreement.

    - These costs may not be covered by insurance and are the responsibility of the Patient.

 

STATEMENT ABOUT HERBAL REMEDIES:

Most herbs used for healthcare have excellent safety reports based on modern research and herb/drug interactions are rare, but possible. Some of these herbal remedies include, but are not limited to, medicinal herbs and plant derivatives prescribed as loose teas and alcohol or glycerin products. Patient acknowledges that Patient will not take herbs during pregnancy or lactation without expert advice. If Patient becomes pregnant while taking herbs, Patient will stop taking them until Patient secures further professional healthcare guidance. Patients will fully and accurately disclose any medications, herbs, and supplements Patient consumes so Practice can offer informed advice, and Practice cannot be held responsible for being provided inaccurate or incomplete information regarding Patient's medications and supplements. Patients will immediately report to Practice (or to any other healthcare professional providing care to Patient) any apparently negative side-effect of any medication or supplement Patient consumers. Given that the FDA estimates that more than 29,000 different dietary supplements are available to consumers, it is impossible for providers to know all the dietary supplements that exist, their use, indications, interactions, and side effects. The risk of herb-herb, herb-drug, and nutrient-herb-drug interactions increase based on the number of supplements consumed. Patients acknowledge that some risk exists to taking dietary supplements and herbal medicines.

 

STATEMENT ABOUT OTHER ALTERNATIVE THERAPIES:

Practice has informed patients of other alternative therapies such as medical nutrition, intravenous therapies, other dietary supplement options, chelation, IV therapies, cupping, electrical stimulation (e-stim) and other similar integrative health services. These other integrative services might or might not provide discernible health benefits. Any integrative 

services have viable alternatives as outlined above, and always pose risks of negative side-effects and/or a failure to deliver improved health outcomes.

STATEMENT ABOUT FUNCTIONAL MEDICINE LABORATORY TESTING:

The purpose of specialty functional medicine laboratory testing that Practice may recommend is to evaluate underlying nutritional, biochemical, and/or physiological imbalances. They can help to identify a need for outside medical referral. The specialty functional medicine lab tests are not intended to diagnose disease. This office utilizes conventional laboratory tests as well as functional medicine assessment to provide a more complete picture of your health and any imbalances.  Functional medicine assessment is designed to assist our doctors and other healthcare providers in our practice to identify the underlying causes of disease, to identify early changes of cellular deterioration, and to assess for optimal health. Functional medicine has evolved through the efforts of clinicians, scientists, and researchers from diverse fields of clinical nutrition, biochemistry, molecular biology, physiology, genetics, conventional medicine, and a wide variety of scientific and medical disciplines. Functional medicine is a systems-based approach to disease, and evaluates the body as a whole, emphasizing the relationship of one physiologic system to another and the nutritional biochemical imbalances and toxic load that may impact the normal function.  Your other doctors or care providers may or may not agree with the necessity for, or our interpretation of, the laboratory tests that we recommend. If you have any questions or concerns, please feel free to discuss them with your provider.

 

STATEMENT ABOUT GENETIC/ GENOMIC AND EPIGENETIC LABORATORY TESTING:

The purpose of genetic/ genomic and epigenetic laboratory testing is to gather genetic and epigenetic data in order to personalize care for you. Everyone inherits a unique combination of gene variants, gene mutations, and epigenetic modifications (epigenetic modifications impact gene expression and "silencing" of gene expression). The gene variants and mutations you may inherit may impact the ability of your body to assimi-late, produce, metabolize, utilize, incorporate, store, or excrete a variety of constituents important for your underlying health, including nutrients, hormones, neurotransmitters, growth factors, enzymes, proteins, li-pids, carbohydrates, or other cellular, structural, or genetic building blocks. You will additionally be informed by each genetic laboratory testing company of the potential risks involved of knowing this data and will generally sign a separate consent for each test by each commercial vendor which Practice urges you to carefully consider. Regarding privacy, we will abide by the stated Privacy agreement and will do our best to keep your genetic data private unless you choose to share this information (see exceptions in Privacy section above). In the event you decide to undergo genetic/ genomic, and/or epigenetic testing. you accept any and all risk to your insurance coverage or employment and accept any mental anguish resulting from understanding your or your family's risk for disease. 

With genetic/ genomic/ epigenetic information Practice may be able to better guide you toward personalized preventive strategies 

for you to maximize your health and vitality, however we understand this is a personal decision that only you can make.

 

NOTICE: Refusal to consent to genetic/ genomic/ epigenetic testing as an innovative, integrative, comple-mentary, or non-standard procedure shall not affect Patient's right to receive ongoing or future Practice care or treatment.

 

SALE OF NUTRITIONAL AND HERBAL DIETARY SUPPLEMENTS:

Our clinic and pharmacy sell dietary supplements, herbal products, vitamins, lab tests, and other health products. Please note however that you are under no obligation to purchase dietary supplements, herbs, vita-mins, or other health products or health foods from our clinic or pharmacy. In order to facilitate care and access to valuable products in a timely manner, as a service to you we may make available certain dietary supplements and health products for sale, 

which you can purchase (or not) and which can be delivered to your home. We also utilize a number of third-party prescription-based dietary supplement dispensaries in order to make quality health products available to you. Practice selects companies and manufacturers we trust based on experience, research, and their reputation. A high-quality supplement is characterized by a high-quality manufacturing process, sourcing of quality ingredients that are verified and unadulterated, screening for contaminants, freedom from allergens, disclosure of additives, if any, and purity of final prod-uct. The best companies also frequently have conducted research using their supplements and therefore may have data on efficacy. Other desirable features are formulations that increase bioavailability of the final product, which often is an added expense. For example, capsules are more bioavailable than hard tablets which may never even dissolve. Complexing with food, mineral salts, and phytosomal or liposomal preparations increase the bioavailability of the constituents resulting in a product that is much more likely to produce a desired nutritional effect. Synergy among products is also a favorable feature. There is a lack of stringent testing requirements to document quality for dietary supplements, therefore product quality varies widely in the commercial marketplace. The dietary supplement brands we recommend all meet our high standard and support predictable results. While the supplements may be more costly than those found in commercial drugstores, pharmacies, big box store shelves, or even health food stores, investing in quality supplements increases the efficacy of treatment and is often worth the expense. Our Practice can guide you, however the decision 

where to buy your supplements is up to you. 

To reiterate, please note however that you are under no obligation to purchase dietary supplements or recommended health products from our clinic or pharmacy or any prescription dispensaries we use, and the decision of what and where to buy is up to you.

 

INFORMED CONSENT REGARDING DELEGATING PHYSICIAN/PROVIDER AND DELEGA-TEE PERFORMING MEDICAL SERVICES:

Your physician or clinician may delegate specific medical services to be performed by a delegate, but the supervising physician/ clinician remains accountable for the services.

The services to be provided by delegate are detailed below and are part of the physician/ provider approved, evidence based protocols.

Delegate may be another health care provider, nurse, nutritionist, health coach, or lifestyle medicine educa-tor, who is trained to provide the services below:

1. Perform initial and serial follow up examination of vital signs and/ or anthropometric measurements

2. Performing symptom-based health assessments

3. Taking, assessing, and reviewing a lifestyle health history

4. Patient education and counseling related to therapeutic food plans, lifestyle changes, etc.

data, etc.

6. Providing education, counseling, and monitoring of food plan and compliant menus

7. Providing education, motivational interviewing support, counseling, and monitoring of exercise/ activity/ fitness plan

8. Providing education, support, counseling regarding implementing therapeutic nutrition protocols

9. Providing education, support, and counseling on stress management techniques to incorporate

10. Providing patient education on sleep, recuperation, and restoration

11. Enter detailed medical record notes of all education/ counseling/ services provided to client during the visit and summarize any progress, obstacles, behavior change and actions clients plan to take.

 

STATEMENT BY CLIENT RECEIVING DELEGATE SERVICES:

Client understands that physician or clinical provider may delegate services listed above to be provided to you by a delegate (for example a health coach or other therapeutic lifestyle educator. Client agrees to receive these services by the delegate which will be supervised by a physician.

INTELLECTUAL PROPERTY:

Except for the electronic health record, and the display of other third party logos and informational content as permitted by licensing agreements, [PRACTICE] retains the right, title to the website, mobile website, business processes, Services, software and any and all education content, trademarks, logos, or other intellectual property developed by the company as defined below that may be shared with you or used by you.  For the purpose of this contract, "intellectual Property" shall be defined as all ideas, concepts, designs, drawings, packages, works of authorship, processes, methodologies, information, developments, materials, 

inventions, improvements, software, websites, and mobile sites, and all intellectual property rights worldwide arising under statutory or common law, including without limitation, all (a) patents and patent applications owned or licensable by a party hereto; (b) rights associated with works of authorship, including copy-rights, copyright applications, copyright registrations, mask work rights, mask work applications and mask work registrations; (c) rights related to protection of trade secrets and confidential information; (d) trade-marks, trade names, service marks and logos; (e) any right analogous to those set forth in clauses (a) through (d); and (f) divisions, continuations, renewals, reissues and extensions of the foregoing (as and to the extent applicable) now existing, hereafter filed, issued or acquired. The information available on the site and the Services are the property of HLH Total Wellness LLC. You hereby agree not to copy, modify, reproduce, sell, lease, publish, license, or distribute the Intellectual Property to anyone else without prior written permission.