Complete New Patient Adult Packet

NEW PATIENT INFORMATION FOR MEDICAL RECORDS (ADULT)

Step 1 of 10

OFFICE POLICY

The following information explains our policies and procedures. Please read it carefully and sign at the bottom. If you have questions, please ask any member of the staff and they will be happy to answer your questions.

SCHEDULE OF FEES

New Patient Consultation: Approx. 45 minutes - $900
New Patient Consultation (Cancer - Autism): Approx. 60 minutes - $1100
Craniosacral Osteopathy: Approx. 45 minutes - $900
Follow-Up Appointment Regular: Approx. 30 minutes - $400
Blood Draw - Processing Fee: $75
Preauthorization for Medications - New Request: $25

We accept all credit cards, debit cards, check or cash. Pricing for treatments, medications, supplements or consultations are subject to change at any time.

Dr. West also provides nutritional supplements, intravenous therapies and certain lab tests which may not be covered or reimbursed by insurance companies.

There is a $25 charge for simple forms or letters requested that Dr. West fills out for her patients. Legal documents are $100. We do not refund opened purchased supplements or products. If the supplement or product has been unopened, we will grant a credit to the patient's account - we charge a 20% restocking fee.

PPO - OUT-OF-NETWORK INSURANCE

If you have a PPO Insurance, you are out-of-network with our office. We can still provide you a HCFA form (Health Insurance Claim Form), which you can submit to your insurance. Please make sure to ask for this form.

We cannot negotiate with a patient’s carrier on their behalf. If you are unsure of your insurance benefits, or have questions regarding reimbursement, please contact your insurance company directly, as the information can often only be communicated to you, the patient.

Please note that your insurance policy is an agreement between you and your carrier. We are not part of a contract with your insurance company and therefore cannot guarantee any level of insurance reimbursement.

If a patient’s insurance carrier refuses payment, for any reason, the patient remains responsible for the charges. Dr. Rachel West Inc. withdraws itself from involvement in out-of-network insurance disputes, but will provide the patient, or their insurance company, with any information that we are capable and able to release.

LABS / SPECIALTY LABS

Dr. West’s office works with various labs (e.g., Great Plains, Quest Diagnostics, Lab Corp, Pacific Medical Laboratory, Health Diagnostics, Doctors Data, Genova,…). This list is not exhaustive and evolves over time. The majority of the aforementioned labs can submit to the patient’s insurance for any blood work/tests done through our office. However, patients can often benefit from our office’s special cash price, which might end up costing you less than the price you would pay if using your insurance.

Additionally, when the patient’s insurance does not cover the full amount billed, the patient is responsible for any unpaid amounts to the labs (i.e., co-payments, co-insurance and/or deductibles). These matters need to be taken up directly with the specific lab used for the patient’s testing. Dr. West cannot be held responsible for any open balances related to payments that the patient’s insurance refused to make for these labs.

PHYSICIAN CONTACT PROTOCOL

If a patient has a reaction to a medication, the best course of action is to stop taking the medication and schedule a follow-up visit.

In most cases, Dr. West is not able to communicate with patients outside of scheduled office visits, as she needs to be able to focus on her patients of the day.

Patients are welcome to send a message to Dr. West’s team via email (assistant@longevity.la and assistant@drrachelwest.com) or text messages: (310) 560-8982 or (310) 913-9961.

Questions that require a medical decision cannot be answered via e-mail; they require an office visit or phone consultation. Consultations may take place over the phone – especially follow-ups, but generally not initial consultations. Phone consultations are billed like regular office visits.

RESCHEDULING & CANCELLATION

To better serve all patients, our office abides by the following Cancellation Policy:
- New Patient Appointment: We charge the scheduled visit price if the visit is cancelled or rescheduled within 48 hours of the appointment.
- Follow-up Appointment: We charge the scheduled visit price if the visit is cancelled or rescheduled within 24 hours of the appointment.
- IV Appointments Same day: $35
- High Dose Ozone 1 business day: $85
By signing below, you (patient or guardian), acknowledge that you have read and agree with all statements written above. You also understand that any visits, treatment or services done through Dr. Rachel West Inc. which are not covered by your insurance, are your responsibility to pay.
Patient Printed Name
Patient or Legal Guardian Signature
Date
MM slash DD slash YYYY

AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

WE CANNOT SHARE ANY OF YOUR MEDICAL INFORMATION WITH A SPOUSE/PARENT/CHILD/FRIEND WITHOUT YOUR AUTHORIZATION

PLEASE FILL OUT THIS FORM IF YOU WANT TO GIVE US THE ABILITY TO COMMUNICATE ABOUT YOUR CARE WITH A SPOUSE/PARENT/ CARE COORDINATOR/FRIEND.

RECIPIENT:

I voluntarily consent to authorize Dr. Rachel West (my health care provider) to use or disclose my health information during the term of this Authorization to the recipient(s) that I have identified below.

I authorize my health care information to be released to the following recipient(s):
Recipient 1 Name
Recipient 1 Relationship to Patient
Recipient 2 Name
Recipient 2 Relationship to Patient
Recipient 3 Name
Recipient 3 Relationship to Patient
Information to be Disclosed
I authorize the release of the following health information: (check the applicable box below)
- All of my health information that the provider has in his or her possession, including information relating to any medical history, physical condition, and any treatment received by me.
- Only the following records or types of health information listed below
If specific records only, list records or types of health information
TERMS:

This Authorization will remain in effect:
From the date of this Authorization until
MM slash DD slash YYYY
Authorization Signature
Authorization Signature Date
MM slash DD slash YYYY
Witness Signature
If Individual is unable to sign this Authorization, please complete the information below:
Name of Guardian
Guardian Date
MM slash DD slash YYYY
Guardian Witness Signature

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.

Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/her claims with reasonable diligence, and the arbitration shall be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses.

Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well.

Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient.

Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with California law.

I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
Physician or Duly Authorized Representative Signature
Physician or Duly Authorized Representative Date
MM slash DD slash YYYY
Print Name of Physician, Medical Group or Association Name
Patient Signature
Patient Signature Date
MM slash DD slash YYYY
Print Patient Name
Patient Representative Signature (if applicable)
Patient Representative Date
MM slash DD slash YYYY
Print Name and Relationship to Patient Representative
Translator Signature (if applicable)
Translator Date
MM slash DD slash YYYY
Print Name of Translator

Informed Consent for Intravenous and Intramuscular Nutritional Therapies

I give Dr. Rachel West, Inc. as well as the Staff at her Office, Longevity Medical Center, permission to perform single or recurring intravenous and intramuscular Nutritional Therapy (“NT”). I am executing this consent to confirm my understanding of the risks, benefits, and alternatives to treatment with NT.

1. Benefits of intravenous and intramuscular Nutritional Therapy

Intravenous and intramuscular Nutritional Therapy (IINT) is used for a variety of conditions which include but are not limited to dehydration, vitamin, mineral and amino acid deficiencies, malabsorption, acute or chronic viral conditions, immune deficiencies, persistent fatigue, brain fog and exposure to chemicals and heavy metals. The various IINT protocols are provided to me according to the guidelines established by the American College of Advancement in Medicine (ACAM), the American Academy of Environmental Medicine (AAEM), and other professional organizations. IINT consists of the application of vitamins (e.g. B1, B2, B5, B6, B12, B complex, C, D), minerals (e.g. magnesium, calcium, sodium, zinc, selenium, trace minerals), amino acids (e.g. taurine, glutathione), anti-oxidants (e.g. Alpha Lipoic Acid) and nutrients (e.g. phosphatidylcholine).

IV Therapy should typically not be done on an empty stomach.

I understand that Dr. West makes no representations, claims or guarantees that my medical problems or conditions will be helped by IV Therapy treatments.

2. Risks of intravenous therapy include, but are not limited to:

Discomfort, bruising or pain at the injection site; skin rash; nausea; dizziness; fatigue; feeling lightheaded, flushing; headache; infection; lowering of blood sugar levels (hypoglycemia); lowering of blood pressure; inflammation of the veins (thrombophlebitis); inflammation of the vein used for injection and/or phlebitis allergies including life threatening anaphylactic reactions, severe allergic reaction, anaphylaxis, cardiac arrest and/or death.

A common objection against IV nutritional therapy is that a patient might delay or forego undergoing a generally accepted medical treatment. In case of cancer and other life-threatening disease, I understand that IV nutritional therapy is best used as an adjunct to the therapy recommended by my oncologist or specialist.

Your signature below means that:
a. You understand the information provided on this form and agree to the foregoing.
b. The procedure(s) set forth above has been adequately explained to you by your physician.
c. You have received all the information and explanation you desire concerning the procedure.
d. You authorize and consent to the performance of the procedure(s).
IV / IM Consent - Printed Name
IV / IM Consent - Signature
IV / IM Consent - Date
MM slash DD slash YYYY

CANCELLATION POLICY

Please let us know as early as possible if you need to change an appointment. Late cancellations or no-shows will be subject to a cancellation fee of the scheduled office visit charge.

To better serve all patients, our office abides by the following cancellation policy:
- New Patient Appointment: We charge the scheduled visit price if the visit is canceled within 48 hours of the scheduled appointment.
- Follow-up Appointment: We charge the scheduled visit price if the visit is canceled within 24 hours of the scheduled appointment.
Please note that we are open 8:30 am – 5:30 pm on Fridays, so cancellations for a Monday appointment need to be done before we close on Friday.

Other Procedure Fees

Due to the time-consuming nature of managing requests from insurance companies, disability forms, etc… Our office charges a nominal fee for the following services.
1. Disability Claims: $4 per page
2. Disability Letter: $40 depending on amount of time required to review your chart
3. Letter of Medical Necessity: $25
4. Jury Duty Forms: $10
5. Copies of Medical Records: $30 for patient - $40 to prep for outside duplication
6. Prior Authorization: This can be a very lengthy process, and there is no guarantee that it is approved. We charge $25/half hour of time spent.
7. E-mails: No charge for e-mails that are a short question and/or short response - $25 for e-mails that involve complex solutions and/or medical decision making.
Due to the high number of e-mails that we receive daily, please be aware that it may take a few days to receive a response.
Cancellation Policy Acknowledgment
- I acknowledge and accept the above policies.
Cancellation Policy - Patient Name
Cancellation Policy - Date
MM slash DD slash YYYY
Cancellation Policy - Signature
Phone
This field is for validation purposes and should be left unchanged.

Complete New Patient Adult Packet

NEW PATIENT INFORMATION FOR MEDICAL RECORDS (ADULT)

Step 1 of 10

Health History Adult Questionnaire

Please answer the questions that are most applicable to you

AUTONOMIC & ACID BASE

SYMPATHETIC:

PARASYMPATHETIC:

SUGAR HANDLING:

CARDIOVASCULAR:

GASTROINTESTINAL & DIGESTION

LIVER & BILIARY:

DIGESTION:

SKIN, NAILS & HAIR:

ENDOCRINE GLANDS

HYPERTHYROID:

HYPOTHYROID:

HYPER-PITUITARY:

HYPO-PITUITARY:

HYPER-ADRENAL:

HYPO-ADRENAL:

FEMALE & MALE SPECIFICS:

FEMALE:

MALE:

MUSCULOSKELETAL & CALCIUM METABOLISM

HEADACHES:

NEUROPSYCHOLOGICAL:

MISCELLANEOUS:

OFFICE POLICY

SCHEDULE OF FEES

PPO - OUT-OF-NETWORK INSURANCE

LABS / SPECIALTY LABS

PHYSICIAN CONTACT PROTOCOL

RESCHEDULING & CANCELLATION

AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Informed Consent for Intravenous and Intramuscular Nutritional Therapies

CANCELLATION POLICY

Other Procedure Fees