Wellness Membership Agreement If you are a human and are seeing this field, please leave it blank. Wellness Membership Agreement $59 per month (single payment of $354) for six months of coverage This agreement outlines the details of your healthcare membership with Truth & Life Nutrition Consultants Inc Your Wellness Healthcare Membership entitles you to 6 months of personalized healthcare. Unlimited contact via phone or email for questions and minor issues. State of the Art, Functional Medicine testing plus many other benefits. The length of your membership is 6 months What’s Included: One 45-minute office visit to be used at your discretion during a six-month period. If you find that you need additional visits you can purchase additional visits for $200 each. You also have an option to purchase unlimited visits for a single payment of $1000. Unlimited visits will only apply to the current 6 month period. Ordering and interpretation of all lab work. Phlebotomy only appointments (blood draw appointments) are included in your membership and do not count toward your office visit limit. Electronic prescribing of any prescription medication recommended by this practice. Unlimited email or phone contact for minor issues or questions. Access to professional grade supplements via a convenient online dispensary at 10% discount off of regular retail price. A secure online patient portal where you can view and download all test results and treatment recommendations. Virtual visits via phone or secure video medicine portal in the event you are unable to come in to the office. Automatic renewal every six months conveniently billed to your credit card on file unless you notify us that you'd like to switch memberships or cancel. Three ONDAMED (pulsed electromagnetic field therapy) treatments 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. This practice does not prescribe any controlled substances. The cost of services provided by doctors or healthcare providers other than Truth & Life Nutrition practitioners such as specialists care. The Details Duration Your membership starts the day you sign and submit this patient agreement. You have 6 months to use your office visit. At the end of each six month period your membership will automatically renew unless you notify us that you would like to switch to the maintenance level or cancel. Upgrades This membership is designed for patients who have no major ongoing health problems that require monitoring or labs more often than once every six months. If during the course of your wellness membership you develop a medical condition that requires more frequent monitoring or lab testing you will be required to purchase additional office visits as needed until time for renewal at which time you will be able to upgrade to the maintenance membership until your condition becomes more stable. Payment Membership will be charged in a single payment of $354 charged to your credit card on file. Your membership will renew automatically at the end of six months unless you notify us that you would like to upgrade or cancel by your scheduled renewal date. Cancellation All requests for cancellation will become effective as of the next scheduled renewal date. Once your membership payment has processed no refund will be issued and you will continue to have access to services for the remainder of that membership period. 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. 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 Email If you are a human and are seeing this field, please leave it blank.