The Fine Print
As you’ve likely gathered by now, Dr. Zelfand isn’t a run-of-the-mill doctor. She does things radically differently, which allows her to offer better quality care for her patients and also create a better quality of life for herself. (Did you know the suicide rate among doctors is at an all time high?) So it’s no surprise, then, that her policies might be a littler different than what you’re accustomed to. Below are all the nitty gritties you’ll need to know, and will be asked to consent to prior to initiating care. We reserve the right to update and change these policies at any time.
(I) INFORMED CONSENT
I hereby consent to treatment by Erica Zelfand, ND and other practitioners, staff members, and interns that are employed by, associated with, or serve as back-up for her, whether or not their names are listed on this form.
Procedures and treatments MAY (or may not) include the following:
> Common diagnostic procedures: blood draws, laboratory, physical exams
> Medical nutrition and dietary supplementation
> Botanical medicine: teas, alcoholic tinctures, capsules, tablets, crèmes, plasters, suppositories, include low-dose toxic botanicals
> Psychological and lifestyle counseling
> Homeopathic medicine: the use of highly diluted quantities of naturally-occurring plants, animals, nosodes, and minerals to gently stimulate the body’s healing responses
> Oriental medicine: cupping, ear seeds
> Lifestyle and hygiene counseling: diet therapy, exercise, sleep, stress management, etc
> Hydrotherapy: the use of heated and cooled water to stimulate circulation and immune response
> Prescription of over-the-counter and pharmaceutical medications
> Hormone replacement: prescription of exogenous hormones such as estrogen, progesterone, testosterone, DHEA, cortisol, thyroid
> Physical medicine: neck and spine/extremity adjustments, joint mobilization, soft-tissue therapies and massage, traction, electrical stimulation
> Minor surgery: skin tag removal, biopsy, excision, placement of sutures
> Escharotic therapy (women only): application of caustic substances to the uterine cervix> Injections: including vitamins, minerals, nutritional compounds, herbs, hormones, anesthetics, neuraltherapy, neuralprolotherapy, trigger point therapy, ozone therapy. Route of delivery include intravenous (IV), intra-muscular (IM), subcutaneous (subQ), and others.
> Hydrotherapy: including the application of hot and cold water, towels, hydrocollator packs, and other delivery methods to stimulate metabolism, detox, and immunity.
> Physiotherapy: including exercises, ultrasound, electrical stimulation, kinesiotaping, and other methods.
> Needles: dry needling, injection therapies such as neuraltherapy and neuralprolo therapy, the injection of medicines, vaccines, anesthestics, nutrients, and other substances
> Neurofeedback: a gentle therapy to balance the brainwaves and calm the nervous system
> Other procedures recommended for my condition(s)
By signing this form, you consent to the above procedures and treatments, as indicated. You will have the opportunity to discuss with your practitioner(s) the various types of treatments proposed for your condition, and the purpose and objectives of these procedures will be explained. Cure or improvement from treatment are not guaranteed.
POTENTIAL RISKS OF TREATMENT
There are some rare but potential risks to treatment and procedures. Some of these risks include, but are not limited to the following:
> Reactions to prescribed substances (herbs, supplements, homeopathics, medications): allergic reaction, unpleasant side effects, or exacerbation of symptoms> Inconvenience of lifestyle changes> Emotional release, emotional distress, healing crisis
> Physical Medicine: Bruising, sprains, fractures (most commonly ribs), disc injuries, dislocations, nerve injuries, strokes (mostly from neck adjustments).
> Minor surgery: infection, scarring, hemorrhage, hyper or hypopigmentation at surgical site
> Escharotics: cramping, bleeding, progression of cellular changes
> Hydrotherapy: Burns or skin irritation, overheating, contact dermatitis, dizziness. Theoretical risks include: exacerbation of autoimmune reactions, heart failure, or malignant metastases.
> Needles and injection therapies: bleeding, bruising or staining, hematoma, longstanding or permanent staining of skin (in particular with iron), muscle soreness, local pain, infection at injection site, injury to a nerve, pneumothorax (punctured lung), allergic reaction which could be life threatening.
> Neurofeedback: aggravation of mental/emotional symptoms
> Notice to pregnant women: All female patients must alert the doctor if they know or suspect that they are pregnant, or if they are nursing a child. Some of the therapies used could present a risk to the mother or baby. In includes calling or messaging the doctor once you learn you are pregnant, to confirm the therapies you’re using the things previously prescribed are safe to continue taking during pregnancy.
> You are welcome to ask about risks and benefits of proposed treatments at any time. You are also free to withdraw your consent and discontinue participation in treatments at any time.
Please notify your provider of any past present or future medical conditions, cancer, or as any new symptom or condition arises (this includes pregnancy for women).
Note that doing an individualized vaccine schedule may place yourself, your child, or other families at risk of contracting certain infectious diseases, some of which may cause permanent symptoms and/or death.
Please note that Dr. Zelfand is not acting as your primary care physician and it recommended that you have a primary care physician. If you have a serious health problem that requires immediate attention and cannot get a same day visit with Dr.Z, you should call your other doctors(s), call 911, or have someone take you to the nearest hospital emergency room. Please note that we do NOT have an after-hours answering service or 24-hour call shifts.
If you notice an adverse effect from one of the components of your health plan, you should discontinue it and contact our office.
We reserve the right to terminate the doctor/patient relationship at any time for any reason, and are under no obligation to state the reason for discontinuing care.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain privacy rights concerning your healthcare information. Under this law, your healthcare provider generally cannot give your information to your employer, use or share your information for marketing or advertising purposes, or share private notes about your mental health counseling sessions without your written consent. As one of your providers, it is our responsibility to keep your information safe and secure. A record will be kept of the health services provided to you. This record will be kept confidential and will NOT be released to others unless required by law or specifically directed by you or your legal representative.
Your record MAY be shared in the following ways:
> For coordination of care; multiple healthcare providers may be involved in your treatment, directly and indirectly.
> With family, friends, relatives, or others that you specifically identified on this form as having access to your health information or treatment.
> With other clinic members, administrative assistant, or students under their tutelage, who are involved in your treatment. Information will only be shared on a need-to-know basis.
> To protect the public’s health, such as reporting when the flu is in the area.
> To make required reports to the police, such as gunshot wounds.
> To obtain payment from third party payers, such as insurance companies.> In other instances as required by law.
> Your provider is also required to report suspected abuse of an elder or child.
ACCESSING YOUR OWN MEDICAL RECORDS
You may look at you health record or request a copy at any time in writing. You may be charged an administrative fee for printed or faxed copies of your record, and it can take up to 30 days for us to deliver your records. Your health records will be kept for a minimum of 7 years after the date of your last visit.
You have the right to make requests on how and with whom your information is shared.
E-MAIL & MESSAGES
E-mail is not confidential. We therefore allow patients to send secure messages through our secure patient portal. Any messages sent will be added to your patient record. Although creating a portal account is free, please note that there may be a fee for care management done through the portal or by phone outside of an office visit. The portal is not a substitute for care. We do not accept phonecalls requests from patients.
Please note that we do NOT have an after-hours answering service or 24-hour call shifts. There is no “on call.”
ALL active patients will be automatically added to our listserv. We reserve the right to send e-mails very infrequently with important clinic updates (such as holiday closures and policy changes). We ask that all active patients stay subscribed to this listserv, so that you can receive important information. We also have an OPTIONAL list serv for those who would like to hear about special events, promotions, and blog/vlog updates. You will NOT be automatically subscribed to this listserv, but may opt-in through our website at your discretion.
Please do not make video or audio recordings of your visits in part or whole without explicitly obtaining the written consent of your doctor at each visit.Your provider has the right to refuse recordings. If you do record sessions (with permission) in part or whole, you agree to use said recordings for personal use only. They may not be shared with others, posted to the internet, quoted in publication, or used in litigation against your doctor.
(III) FINANCIAL POLICY
CREDIT CARD ON FILE:
ALL active patients are required to have a current credit card on file. This is mandatory if you wish to be a patient at this clinic. Please bring a credit card to your first appointment.
Payment for all office visits (whether or not you have insurance) and medicinary items is due in full at the time of service or time of scheduling the appointment, whichever is earlier. We accept cash, in state checks (with ID), Visa, Mastercard, and Discover. Returned checks will incur a fee.
PAYMENT IS DUE IN FULL AT THE TIME OF SERVICE, regardless of if you have insurance or not. Courtesy insurance billing information is provided via a written invoice (superbill) to patients who request insurance documentation. You may submit this document to your insurance for reimbursement if you desire. If you have out of network benefits, your insurance provider will likely mail a check to reimburse you in part or whole for your visit. If you do not have out of network benefits, your insurance may apply the money spent towards your deductible. Dr. Zelfand is not currently recognized as an in-network provider under any insurance plans and does not plan to ever be. We do not guarantee any reimbursement or coverage from your insurance provider. Most insurance plans do not reimburse for telephone or Skype appointments.
MEDICAID (OHP, ETC.), MEDICARE, TRICARE, AND V.A. (MILITARY)
Please note that state or federal programs like Medicaid (OHP, OregonCare, etc.), Medicare, and Tri-Care neither cover nor encourage services provided by an out of network provider. They likewise will not pay for labwork ordered by an out of network provider. By becoming a patient at this clinic, you agree NOT to submit superbills or receipts to your state or federal insurance company for services provided at this clinic. (Doing so could get your health insurance suspended.) Being a patient here means working entirely out of the Medicaid/Medicare/Tri-Care system. You will be responsible for all expenses incurred out of pocket. You may be able to get these services covered by your insurance if you see another doctor or clinic; call Medicaid/Medicare/TriCare for information on how to find a provider covered by your plan. You may be asked to sign a form before every and any visit at our clinic attesting that you understand and agree to the above. We apologize for this inconvenience, but sadly have little if any say in the matter.
PHONE CALLS AND ELECTRONIC MESSAGES:
Simple questions (clarification of supplement dosing, etc.) will be addressed free of charge. Issues managed by phone or through portal message that include either a new complaint, request for a new prescription, changes to a treatment plan, management of a new symptom, medication refills outside of office visits, or any matter that takes more than a minute of the doctor’s or staff’s time will incur a fee, and will be charged to the card on file. Please do not call the office; send portal messages if you need to communicate with us.
MISSED APPOINTMENTS AND LATE CANCELLATIONS:
For new patient visits: $100 will be charged for missed appointments or cancellations made with less than 48 hours’ notice. This fee must be paid whether you reschedule or not.
Follow up visits: You will be charged a $50 fee for any missed appointments or cancellations made with less than 24 hours’ notice.
This fee will be automatically charged to the credit card on file. This policy does include Monday appointments, as well as emergencies.
We understand that sometimes patients arrive late for appointments due to unforeseen circumstances. As a courtesy to other patients and to the Doctor, we must nevertheless end your appointment at the scheduled time if you arrive late. (For example, If your appointment was scheduled for 1-1:45 pm and you arrive at 1:10, the visit will still end at 1:45 pm). You will still be charged for a full visit, and may be required to make another appointment to finish whatever wasn’t covered in your truncated session.
If you are more than 15 minutes late for your appointment, we reserve the right to cancel your appointment and charge a $50 no-show fee ($100 for new patient visits) to the credit card on file.
We reserve the right to dismiss from the practice patients who no show or late cancel more than three times, even if the appropriate fees are paid.
Your provider may prescribe medications, supplements, botanicals, homeopathics, and other products that may be purchased on site, through our online shop, or elsewhere.
Most insurance companies do not cover the natural pharmacy items we prescribe and dispense, though some FSA and HSA accounts will. We do not guarantee coverage.
BLOOD TESTS AND LABORATORY TESTS:
Your provider may order laboratory testing (blood tests, etc) as indicated. We do not guarantee that your insurance will cover these tests in part or whole. Checking coverage is the patient’s responsibility. Call your insurance company for more information. If you wish to have your blood drawn elsewhere, let your provider know and you will be given a requisition to take to a lab of your choosing.
It is our clinic policy that we do NOT release lab results to patients outside of scheduled appointments where those results can be discussed.