OHANAHEALTH AND WELLNESS

DIRECT: 971-201-7993 fax: 1-844-766-1788

www.ohanahealthandwellnesspdx.com

AUTHORIZATIONSANDOFFICEPOLICIES

Beforetreatmentcommences,pleasereadandinitialthefollowingstatements:

CONSENTTOOBTAINPRESCRIPTIONHISTORY_______IauthorizeOhanaHealthandWellnesstodownloadmyMedicationHistory.ThroughourElectronicMedicalRecordssystemwithAthenahealth,OhanaHealthandWellnesscanimportthelast13months of yourmedication history. This information is downloaded from the pharmacy benefits managerutilizedbyyourhealthinsuranceplace.FINANCIALPOLICY______Iunderstandthat,regardlessofmyassignedinsurancebenefits,Iamfinanciallyresponsibleforpaymentofservicesrenderedtome.Ifthephysicianinvolvedinmycareacceptsthird-partyreimbursementforallorpartofthe services I receive, I hereby agree to assign such benefits to OhanaHealth andWellness and authorizemyinsurancecompanytomakepaymentdirectlytoOhanaHealthandWellness.IunderstandthatOhanaHealthandWellnessmaydisclose a limitedamountof health information to third-parties toobtainpayment for thehealthcare services provided. Please be aware that some insurance companiesmaydetermine treatment to be non-coveredorfinditnottobereasonableornecessary.Ifsuchadeterminationismade,youwillberesponsibleforsuchservices.Weacceptcash,checks,Visa,MasterCard,AmericanExpressandDiscover.Returnedchecksincura$50processingfee.CANCELLATIONANDMISSEDAPPOINTMENTPOLICY_______IunderstandthatOhanaHealthandWellnessrequires24hoursadvancednoticetocancelorre-scheduleanappointment. Iunderstanda fee($25+dependingon theappointment type)maybechargedtomyaccount formissedappointmentsorappointmentscancelledwithlessthantherequirednotice.FORMFEES_______ IunderstandthatOhanaHealthandWellnessmaycharge for thecompletionof formsthatrequireeitherstafforphysiciantimetocomplete.Thechargeforthisservicewillstartat$10dependingonthecomplexityandtime required. This includes, but is not limited tomedication forms, letters, andFMLA forms. The feemaybewaived(excludingFMLA)iftheformispresentedatanappointmenttoseethephysician.CONSENTTOCONTACTVIAEMAIL_______TotheextentthatournewMedicalRecordsoftwareallowsit,wemaybeabletocontactyouviaemailtoremindyouofappointments.

OHANAHEALTH AND WELLNESS

DIRECT: 971-201-7993 fax: 1-844-766-1788

www.ohanahealthandwellnesspdx.com

CONSENTTOCOMMUNICATEPROTECTEDHEALTHINFORMATIONIauthorizeOhanaHealthandWellnesstocommunicatemyprotectedhealthinformation(includingappointmentreminders)tomeviathefollowingmethods:______Detailedmessageonmyhomeansweringmachine.______Detailedmessageonmypersonallyidentifiablecellphonevoicemail.PHONECALLS/PATIENTPORTALMESSAGES_______Phonecallsandportalmessagesregardinganexistinghealthissuethatrequiresmorethan10minutesofattention from your physicianwill incur a fee. Phone calls and portalmessages regarding a newhealth issue,regardlessof the lengthof timeandattentionrequired,willalso incura fee. Phoneandpatientportalmessagechargesmaynotbebillabletoinsurance.Pleasenotethatnonewprescriptionswillbegivenviaphoneorpatientportalmessages.HOMEVISITS _______Homevisitsaresubjecttoanadditionaltransportationfee.EMERGENCYCARE ______OhanaHealthandWellnessdoesnotprovideemergencymedicalcare.Ifyouareconcernedthatyoumightbeexperiencingamedicalemergency,pleasecall911orgotoyournearestemergencyfacility.Pleasecontactourofficethefollowingdaytoinformusofthedetailsoftheevent.SUPPLEMENTS______ Payment in full is expected at time of purchase. We appreciate you supporting local businesses bypurchasingyourprofessional,high-qualitysupplementsthroughOhanaHealthandWellness. IunderstandthatIamnotrequiredtopurchaserecommendedsupplements fromOhanaHealthandWellness. Pleasenotewemaynotbeabletorefundanyproductonceithaslefttheclinicpremises.ACKNOWLEDGMENTToindicatethatyouhavereadandunderstandthesepolicies,pleasesignbelow._____________________________________________________________________________________________ ___________________________________Patient/LegalGuardianSignature Date_____________________________________________________________________________________________Patientname(Pleaseprint.Includelegalguardianifpatientisaminor)