CLIENT AGREEMENT - LV WELLNESS CONSULTING, LLC

In order to best serve you, the Client Acceptance Policy should be carefully reviewed. It is our opinion that you  should be well informed on our expectations and recommendations. To prevent any misunderstandings or confusion on what to expect, we would appreciate that you read the below steps and provide your signature. This will attest to the fact that you have read the Client Acceptance Policy and understand what is expected of you, as  well as what to expect from working with us. 

It is very important for you to carefully and thoroughly complete all of the new patient forms and questionnaires prior to your first session.

The questionnaires supplied to you to complete were developed to gather important information about your  previous medical care, current health complaints, lifestyle, eating habits and mindset. It will guide us in helping you. These questionnaires will allow your coach to correctly pinpoint the most probable explanations of your health symptoms. However, your health coaches are in no way diagnosing, treating, or acting as a medical professional, even if he/she may contain an active medical licensure. You will be given recommendations only, and no medical treatment will take place. 

Please review the below:

1. We will not be ordering any insurance covered services, or filing for your insurance. No ICD-10 codes will be supplied, as she is in no way diagnosing or treating.
2. If you have not had a physical examination within the last year or since the start of your most recent health problem, it is highly recommended to schedule an appointment with your primary physician within a reasonable time after starting with the coaching process, as your team will not be doing any physical examination or seeing you in person. Other things such as ultrasounds, scans, or traditional laboratory testing would also be completed outside of this contract with you, we will not order any such testing.

3. Correspondence by e-mail or other means is acceptable and encouraged for any questions. Note that any correspondence via text, email, phone, video, Facebook, Instagram, or any other means during and after your entire relationship with us is not HIPAA or medically secure, and you share information on these platforms willingly.

4. We will do the best to accommodate all scheduling needs. It is your responsibility to reach out and inquire about setting up a time for your appointment, or scheduling if nothing is available on the online calendar provided.

5. Payment for this package must be paid in full, or in the agreed upon means. No services will be provided prior to payment.

6. There will be no refunds of payment, for any reason, despite it the client completes his/her time with us.

AUTHORIZATION OF CONSULTATIONS:

I hereby authorize health, mindset, lifestyle, and nutritional, and other such recommendations for myself or my minor child by LV Wellness Consulting, LLC.

NOTICE AS TO NATURE OF SERVICES: I seek the health coaching services of the Company, employees and staff. I understand that this company uses some recommendations that some may be considered holistic, complementary or alternative. Some of these methods have not been accepted by mainstream medicine. I understand that the principles of this practice are based on Functional Medicine, a health system, in which we believe that the body has an inherent ability to heal itself given the right tools. Not all treatment modalities provided by team members are based on science-based evidence. In no way is this team asserting or implying to holding themselves out to be a Medical Doctor (MD), Nurse Practitioner (NP), or any other medical professional in this consulting relationship. Furthermore, the term “patient” may be utilized, and is understood as a customary term and does not imply or expressly constitute a conventional doctor/patient relationship has been established. The term “client” will be most solely used. I fully understand that the advice and recommendations that are provided by the Company are not to be considered medical advice and are for informational and educational purposes only.

NOTICE THAT SERVICES ARE NOT PRIMARY CARE: I understand that no physician or any other practitioner that I see through the Company is acting as my primary care physician. As such, emergency services are not offered. I understand that even though my consultants may address issues affecting my general health, the practice is focused on a complementary, functional, holistic approach to health care and it is required to have a primary care physician to ensure that I am fully appraised of all available conventional means to address any medical conditions that I may have.  This is also important because these practices are exclusively virtual-based and are not affiliated with a hospital. If I become so ill that I require hospitalization, it is vital that I have a primary care physician with hospital admitting privileges familiar with my health problems and history. I understand that in addition to a primary care physician, it may be in my best interest to have appropriate specialists, such as a cardiologist if I have cardiac problems or a pediatrician if I am seeking treatment for my children.

NO GUARANTEES: I understand that the Company does not make any representations, claims or guarantees that I will be helped with my medical problems or conditions by undergoing consultations with them. However, they will do the best to help me accomplish my health and wellness goals.

REVOCATION OF AUTHORIZATIONS: These authorizations will remain active unless revoked by me in writing at any time. I understand such revocation will not affect my financial responsibility to pay for services rendered.

STATE LAW: The law that governs this relationship is the law of South Carolina.

INSURANCE CLAIM MANAGEMENT: We do not participate nor are contracted with any insurance company. We will not provide a receipt and an encounter form to submit to insurance, and do not prepare or submit insurance claim forms. We are not obligated to respond to insurance carrier requests for information, and are not obligated to take action on my behalf against an insurance carrier for collecting or negotiating my any claim.

I am responsible for the payment of services provided by the Company at the time of service without regard to insurance coverage. I am entitled to know the cost of all services and procedures in advance and it is my responsibility to ask if they are not told to me.

FINANCIAL INSURANCE RESPONSIBILITY FOR ALL SERVICES: Any and all past due patient balances, if applicable, will be collected before my appointment. We are committed to providing the best consultations for clients. All appointments are considered confirmed at the time they are made. I understand all payments must be made prior to appointment time. Because a substantial amount of time has been set-aside for me, I will forfeit any charges for a missed appointment. If an appointment is missed, I am not guaranteed a make-up appointment for that week, it is my responsibility to re-schedule, and my allotted time with the Company will not be extended, under any circumstances. If I need to miss appointments due to illness, vacation, travel, or family emergencies, I am not guaranteed additional appointments to make up for that time, and will still be responsible for the cost of that appointment. I understand that I need to make my best attempt to contact my consultant 48 hours in advance if I cannot keep the appointment.

It is clear that there will be no refunds for any services agreed upon by myself and the Company. If I pay in full and am unable or unwilling to complete my time with this company, regardless of how much time, if any, we have spent together, I do not receive a refund for my payment. 

CLIENT ACKNOWLEDGEMENT: I certify that I am here to receive consultation services only and/or they are not substitutes for appropriate medical care. I do not represent any third party. I have read and understood the conditions described above. 

TERMS AND SERVICES: Client agrees to pay the Company a total amount of Five Hundred Fifteen ($515) USD, which shall be paid via wire transfer or agreed upon method of payment. The duration of the session will be ninety (90) minutes. I understand that I have the right to review this consent with an attorney if I choose before accepting any coaching or services. I have executed this consent freely and willingly understand its provisions. I recognize that the Company will rely upon my signing of this document in accepting me as a client and establishing me under legal contract. I acknowledge receipt of a copy of this consent if I have requested it. The goal of this 90-minute session is to help the coach to pinpoint the most probable explanations of your health experience or complaints.

I do hereby acknowledge that by signing this statement of understanding that I understand that some, and perhaps all, of the discussion involved during this 90-minute session may be innovative, non-traditional or unconventional and is not to be construed to qualify as medical or nutritional advice and it is for informational and educational purposes only. I also understand that these unconventional services may be viewed by 3rd party insurance purveyors as non-covered services, in that they might be considered unreasonable or unnecessary under any medical insurance program. I also realize that my insurance coverage does not pay for such services and that I will be personally responsible for payment. I understand that I will pay all costs including reasonable attorney fees, should that become necessary. I understand  that all outstanding balances bear interest at the maximum rate allowed by law. 

I understand that my acceptance of these terms represents full informed consent for any and all treatments, services, and recommendations offered and given to me or my minor and that I will not be required to sign individually separate consent forms for any protocols or recommendations received during time with the company.