True Health Membership Agreement-Female-$400 PP If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. True Health Annual Membership Agreement Four quarterly payments of $400 This agreement outlines the details of your healthcare membership with Truth & Life Nutrition Consultants Inc Your True Health Annual Membership entitles you to a full year of personalized healthcare comprised of over 250 minutes with your certified Functional Medicine practitioner. Unlimited contact via email for questions or minor issues. State of the Art, Functional Medicine testing plus many other benefits. A 12 month commitment is required What’s Included: Five Functional Medicine office visits. Office visits consist of an initial 90 minute comprehensive visit where a thorough medical and personal history will be taken. A physical examination will be performed including a complete body composition analysis. You will then receive four 45 minute follow-up visits to be used at your discretion throughout the year. A comprehensive six part nutrition and lifestyle plan, providing specific recommendations regarding testing, nutrition, exercise, stress, sleep and supplements and prescription medications if needed. Prescribing, monitoring and processing refills for all prescription medications recommended by this practice. Six 30-minute professional coaching sessions with our certified health and lifestyle coach. Unlimited email contact for minor issues or questions Access to professional grade supplements via a convenient online dispensary at 10% discount off of regular retail price. Unlimited ONDAMED (Pulsed electromagnetic field therapy) treatments. (Subject to scheduling availability) A secure online patient portal where you can view and download all test results and treatment recommendations and even message you care provider. Virtual visits via phone or secure video medicine portal in the event you are unable to come in to the office. (Initial visits must be in person) What’s Not Included: The cost of supplements purchased through our online dispensary or other retailers. (You will however receive a 10% discount on supplements purchased through our dispensary) Laboratory test costs Most lab tests are fully or partially covered by your health insurance plan. Some may not be covered or may require a co-pay. All planned testing will be discussed and potential out of pocket costs will be disclosed and agreed upon prior to any testing. The cost of medications whether prescribed or over the counter The cost of services provided by doctors or healthcare providers other than Truth & Life Nutrition practitioners such as specialists care. This practice does not prescribe any controlled substances such as opiate containing pain medications or benzodiazepams such as Xanax, Valium or Klonopin. The Details Duration Your membership starts the day you register. You have 12 months to use your 5 visits. After that time your membership may be renewed at the maintenance or wellness level. If you have not used all your visits within a year they do not roll over. Payment $400 upon submission of this form followed by three additional payments of $400 every three months. ($1600 total) Cancellation You have 30 days from the day you register to change your mind and receive a full refund provided you have not yet had your initial visit. If you have already had your initial visit and are dissatisfied for any reason, if it is within 60 days of your initial registration date, you may cancel your membership for a full refund minus $400 to cover the cost of services already rendered. Once you have had your second visit or your membership has been active for more than 60 days, your membership is not refundable and you will be responsible for payment for the full year. There is a 24 hour cancellation policy for all appointments. If appointments are missed or cancelled with less than 24hrs notice it will result in a $50 charge to the credit card on file. Additional Policies You may be able to submit your receipts to insurance and depending upon your policy rules your insurance may cover out of network services. We will not submit insurance claims on your behalf. We are not your Primary Care Physician. Although we are able to provide many of the services of a primary care physician like prescribing medications and ordering lab tests we do not meet your insurance company’s requirement for a primary care physician. We therefore recommend that you maintain a relationship with a primary care physician. If we identify a problem that warrants referral to a specialist we will make that recommendation to you and will provide you with all applicable test results to discuss with both your primary physician and the specialist of your choice. Lab Tests Most lab tests ordered will be billed directly to your insurance by the lab. Some lab tests we offer as part of our functional medicine testing program may not be covered by insurance and in these cases you will be charged a fee for a particular test by the lab. The specific test ordered will be personalized to you based on your initial evaluation and may include blood, saliva, urine or stool testing. We will make every effort to make you fully aware of any additional lab fees that may be incurred and to give you the opportunity to choose which lab tests you feel comfortable paying for. You are under no obligation to purchase any specialty testing As a member you are not charged anything to have your specimens collected by our staff at our office. You may also elect to have your specimen collected at a local collection center of your choice such as a Quest facility, in which case we will provide you with the documentation you need via the patient portal. Your Truth & Life Nutrition Healthcare Membership Is Personal To You! It may not be shared, assigned or transferred to anyone else even if you are not using it. What happens after your first year? After your first 12 months of membership all existing members are eligible to renew their membership at the Maintenance or Wellness level. At the Maintenance level you will enjoy one office visit every 3 months and at the Wellness level you will enjoy one office visit every 6 months. Both levels also provide many of the other benefits included in the True Health Annual Membership. Currently the monthly cost for renewal at the Maintenance level is $79 per month ($237) for a three month commitment and the Wellness level is $59 per month ($354) for a six month commitment. Notice as to Nature of Services I understand that care received at Truth & Life Nutrition Consultants Inc. may be non-traditional or unconventional. Such services are commonly referred to as complementary or alternative medicine (CAM), holistic, or innovative services. This can include nutritional and herbal consultation, including alternative approaches to hormonal difficulties, and innovative laboratory testing and diagnosis. Many of these services may not be recognized as standard medical practice, and while long practiced may still be considered investigational or experimental by the conventional medical community. Do you agree with the terms and conditions of membership as described above? * First Name * Last Name * Address 1 * City * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State * Zip / Post Code * Phone * Email * If you are a human and are seeing this field, please leave it blank.