PRIVATE PRACTICE-PATIENT AGREEMENT
which, you, the undersigned patient (“Patient”) may voluntarily elect to enroll in the mental health exam services offered by New U Therapy Center & Family Services, Inc., a California corporation (“Practice”), with such services further described in Schedule A and as follows
assessment Exam Services consult after which either Patient or Practice may then immediately provide written notice to terminate the Agreement and discontinue Exam Services/Services Fees should either Patient or Practice elect to do so for any reason in Patient’s or Practice’s sole discretion in ten (10) days after that initial Exam. Otherwise, the Agreement remains non-terminated, the first three (3) months of Services become non-refundable (due to the heavy investment of initial Practice time to organize Patient Exam Services, and Patient shall pay the remaining Services Fees owed monthly or annually (see Schedule A) pursuant to Agreement terms with a debit card, credit card, or ACH to secure the availability of ongoing further Exam Services. If paying by card, Patient is required to keep a valid card on file with Practice during the term of this Agreement. Patient authorizes Practice to automatically charge the card on file for the applicable Services Fees monthly or annually unless Patient has provided timely written notice to terminate this Agreement. Patient is solely responsible for updating card information, if any changes occur, to ensure uninterrupted billing.
Services Fees are designed to qualify as eligible medical expenses such that Patient may pay Services Fees with health saving account (“HSA”) funds, flexible spending account (“FSA”) funds, health reimbursement account (“HRA”) funds, or similar funds, or via employer funding, but this qualification is not assured or promised. Patient must confirm HSA eligibility with Patient’s tax
labor/ERISA/tax legal counsel, as Practice cannot guarantee medical expense eligibility due to variable factors applicable to each Patient
terminated by either Party with thirty (30) days’ written notice. During this thirty (30) day written notice period, Practice shall continue to provide Exam Services to Patient through the effective date of termination.
FINANCIAL POLICY AGREEMENT
EXAM SERVICES & SERVICES FEES
INFORMED CONSENT
Exam Services are entirely beyond and exceed what any Plan covers or reimburses.
Exam Services shall integrate the following health principles and goals:
focused on proactive mitigation and management;
● Creating and guiding Exam Services-based lifestyle goals;
● Providing Patient with enhanced health education and improving overall health knowledge;
● Improving awareness regarding an expansive array of healthcare services and options
treatments, medications, and procedures that, unless Patient’s Plan reimburses, shall constitute out- of-pocket Patient costs. Patient may submit to Patient’s Plan for reimbursement of these costs, but reimbursement is not guaranteed. Patient must pay for these out-of-pocket costs as they are not included in or covered by Services Fees
$10,000.00/year
● Unlimited follow-up mental health-focused Exam Services exams
● One (1) Exam Services supportive communication per week
● Functional nutritionist’s Exam Services that include nutritional plan
$25,000.00/year
● Unlimited ongoing Exam Services supportive communications
and art events
psychiatric clinician’s recommendation
and art events)
services, collectively aimed at improving Patient’s overall health. Practice’s reduced patient panel, and detachment from dependence on Plan reimbursement for Plan services that often include
restrictions or limits on those Plan services, all enable Practice to provide expedited and unhurried
exam and supportive communication services. All services paid for by Services Fees are entirely
outside of and beyond any Plan coverage. Services Fees must never be submitted to Medicare or any other Plan for reimbursement
Practice is in-network with Patient’s Plan. Plan-covered services will be submitted to the Plan for
reimbursement, and Plan-mandated co-payments/deductible charges shall be collected from Patient by Practice.
Medicare-eligible patients may request and receive Medicare-covered services. Practice must bill
Medicare for these services and must collect Medicare-mandated co-payments, deductibles, and other Patient charges related to Medicare-covered services
experience some, little, or no health improvement. Health outcomes depend on a wide range of
individual factors. Patient considers the potential benefits, risks, and alternatives of Exam Services when consenting to such services
research on many Exam Services is ongoing, and long-term safety and efficacy data may be limited.
disclose all known medical conditions, diagnoses, allergies, and personal and family health history; (b) disclose all prescription and non-prescription medications, vitamins, supplements, and herbal products currently being taken or planned; (c) promptly report any side effects, adverse reactions, or worsening conditions; (d) notify Practice immediately upon learning of an existing or planned pregnancy; and (e) comply with all recommended monitoring, follow-up appointments,
dosage/frequency of treatments, and laboratory or diagnostic testing.
results are guaranteed; (b) side effects, adverse reactions, and negative outcomes are possible; and (c) Patient may decline or discontinue any service at any time.
Exam Services (“Amino Acid Therapies”). Amino Acid Therapies address various physiological processes and may support metabolic function and weight management, immune modulation, tissue and musculoskeletal repair, growth hormone pathway activity, cellular energy optimization, and general wellness. Some preparations may be compounded under applicable pharmacy compounding laws and Pharmacy Compounding Accreditation Board (“PCAB”) guidelines; compounded medications are not FDA-approved. Although Practice may offer information on reputable compounding pharmacies for convenience or cost comparison, Patient may use any pharmacy, and Practice derives no financial benefit from that selection.
efficacy data and are considered non-allopathic and subject to ongoing debate. Where consistent results are achievable, sustained administration over a variable period is generally necessary. No results are guaranteed, outcomes vary by individual, and no refunds are provided for prescriptions
once filled
cramping, and appetite changes) may be pronounced in some patients. Neurological and
cardiovascular effects may include headache, dizziness, palpitations, blood pressure changes, and, in
medications face a risk of hypoglycemia requiring dosage coordination with Practice. Preparations
affecting immune pathways carry a theoretical risk of immune over-stimulation in patients with autoimmune conditions. Certain preparations may theoretically accelerate abnormal tissue growth (tumorigenesis); patients with a personal or family history of cancer, specific thyroid cancers, or multiple endocrine neoplasia syndromes must disclose that history before initiating treatment, and Practice will evaluate contraindications individually. Additional risks include injection site reactions, drug interactions, and central nervous system effects such as agitation or sleep disturbance. Practice does not recommend Amino Acid Therapies during pregnancy. Competitive athletes should consult their applicable anti-doping organization before initiating use.
minerals, herbal compounds, etc.) (“Supplement Guidance”). Supplement Guidance supports general health and wellness but is not always recognized as medically necessary or clinically effective under allopathic medicine. Many supplements are not FDA-approved to diagnose, treat, cure, or prevent any condition, and labeling claims may not reflect clinically proven outcomes. Practice does not manufacture, package, test, or control the quality of third-party supplements and makes no representations as to their safety, purity, or efficacy. Positive results are neither promised nor guaranteed.
supplements or medications. Certain supplements interact adversely with prescription medications, affect liver or kidney function at elevated doses, or produce adverse effects in patients with specific conditions or allergies
alternatives to treatments when weighing consent to certain Exam Services
symptoms or health markers following any treatment may be attributable in whole or in part to the
passage of time and the body’s own restorative processes, rather than to any particular treatment
received.
improvements in symptoms as a result of receiving a treatment that is described as a health treatment when factually there is no anticipated treatment function. Patient should consider that subjective improvement following Exam Services (particularly those with limited long-term clinical data) may reflect the placebo effect rather than the actual specific treatment received. This is a relevant consideration in evaluating the necessity of any particular Exam Services.
among the most powerful determinants of health outcomes. Many health challenges may correlate with suboptimal nutrition, physical inactivity, poor sleep, chronic stress, unresolved emotional difficulty, substance use, or inadequate social support. Healthcare professionals including nutritionists, dietitians, physical therapists, mental health counselors, and health coaches provide evidence-based support in these areas with substantial and durable results. Practice encourages Patient to treat improvements in lifestyle, diet, and mental and emotional well-being as a central component of any health strategy.
oral medications, behavioral health support, and lifestyle modification) represent important
Patient’s conditions or goals differently than Practice. Patient is encouraged to discuss all available options with Practice, seek second opinions where helpful, and maintain open communication with all treating providers.
ELECTRONIC COMMUNICATIONS AGREEMENT
undersigned patient (“you” or “Patient”) enter into this Electronic Communications Agreement (“EC Agreement”) regarding the use of e-communications/transmissions, such as e-mail, mobile or cellular telephone (if applicable), Zoom, FaceTime, internet portal-enabled communications, SMS or text or DM messaging, or, any other version of electronic communication (collectively “E-Communication”) concerning Patient protected health information (“PHI”). (Practice and Patient are each a “Party” or collectively the “Parties”)
immediate communication, you acknowledge there are E-Communication risks that are outside Practice’s control. You authorize all forms of E-Communications exchanged between Parties unless you instruct us otherwise in writing. You acknowledge that the use of E-Communication is inherently risky and prone to unintentional release of data. E-Communications may incorporate or communicate references to your PHI with sensitive health and personal identification information included. You acknowledge that E-Communications lack any guarantee of privacy and are subject to system privacy failure, cookies and other tracking efforts, phishing attacks, hacking attacks, data breaches, unintended misdirections, misidentifications of senders/recipients, technology failures, and user errors.
contact information, phone number, and any other applicable E-Communication contact information). You will immediately inform us of any changes or corrections to your electronic contact information to avoid misdirected E-Communications. You will also inform us of your permanent mailing residential address, and any changes to that address
of time. You agree not to utilize E-Communications to contact us regarding an emergency or time-sensitive situation, as there is too much risk that the communication response may be delayed, ineffective, untimely, or inadequate. You MUST call 9-1-1 in an emergency and/or immediately seek emergency medical attention
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
New U Therapy Center & Family Services, Inc., a California corporation (“Practice”), is required to provide Patient with a copy of Practice’s Notice of Privacy Practices (“Notice”) that states how Practice may use and/or disclose Patient’s health information.
You may refuse to sign this acknowledgment if you wish.
I acknowledge that I have received a copy of Practice’s Notice of Privacy Practices.
NOTICE OF PRIVACY PRACTICES
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
New U Therapy Center & Family Services, Inc., a California corporation (“we”, “us”, “our”, “Practice”), understands that patient (“you”, “your”) privacy is important. This Notice of Privacy Practices (“Notice”) applies to Practice and each of our Business Associates, as applicable.
We are required by law to preserve the privacy and security of your PHI. While there is no guarantee of privacy, we are committed to protecting your privacy. We have established reasonable and appropriate measures to protect your PHI against unauthorized uses and disclosures. Federal law mandates that we share this Notice with you and that we make a good-faith effort to obtain a signed document acknowledging your receipt of this Notice. We are also required to follow the terms of this Notice. If we are involved in a breach of your PHI, we will immediately notify you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition
Preventing disease;
Helping with product recalls;
Reporting adverse reactions to medications;
Reporting suspected abuse, neglect, or domestic violence; and
Preventing or reducing a serious threat to anyone’s health or safety
To comply with the law
We can share your PHI with a coroner, medical examiner, or funeral director at end-of-life.
For workers’ compensation claims;
For law enforcement purposes or with a law enforcement official;
With health oversight agencies for activities authorized by law; and
For special government functions such as military, national security, and presidential protective services.
To respond to lawsuits and legal actions
We can use and disclose your PHI in certain situations with your verbal or written agreement
You may request an electronic or paper copy of your PHI medical record
Ask us to limit what PHI we use or share
We are not required to agree to your request, and we may say “no” if we believe that would affect your care. Because you are privately paying for some medical or health services, you may ask us to refrain from sharing PHI related to those private pay services with your health insurance plan. We will respect that request unless we are legally obligated otherwise under applicable laws
Choose someone to act for you
Attention: Inna Lee, LMFT, CCHt
25000 Ave Stanford, Ste #167
Valencia, CA 91355
[email protected]
Provider: New U Therapy Center & Family Services, Inc.
