New Patient Introduction and Authorization

Welcome to Monarch Integrative Health! We are delighted to have you as a new patient, and we look forward to providing you with the highest quality healthcare. To ensure that we offer you the best possible care, we kindly ask you to complete this comprehensive new patient form. We understand that this form is quite extensive, comprising 25 pages, and may take approximately 1-2 hours to complete. Please be aware that once you begin filling out the form, you won't be able to save your progress and reopen it later. It is important to allocate sufficient time to complete the entire form in one sitting.

Your health and well-being are our top priorities, and the information you provide in this form will play a crucial role in tailoring our services to your unique needs. We appreciate your dedication to completing this form thoroughly and accurately.

If you have any questions or need assistance while filling out the form, please don't hesitate to reach out to our staff, who will be more than happy to assist you. We value your trust in our practice and are committed to delivering the best possible healthcare experience.

Thank you for choosing Monarch Integrative Health.

SIGNATURES: can be manual, copied, or typed; upon sending this information to Monarch Integrative Health, signature shall be binding between patient and provider.

Introduction

Thank you for choosing our practice for your prevention and wellness care.  We are an adult care practice that focuses on Integrative & Functional Medicine approaches to achieve wellness. As a critical part to helping you, we are asking that you to complete this new patient paperwork prior to your initial consultation.  Our goal is to maximize your time with our practitioners to improve your overall personal wellness and determine the best path for prevention.

During your first consultation, you will be asked to arrive 15 minutes early to review your completed paperwork with the staff and initial medical checks prior to meeting with a practitioner.  After you schedule your appointment online you, will receive a confirmation email confirming your appointment date and arrival time.  It is important to complete every single page, which includes your correct legal name and signatures/initials on every page.  If you have any questions, please feel free to contact our office prior arrival or ask the receptionist when you submit your paperwork.   

The new patient paperwork consists of a very comprehensive list of questions about every aspect of your health history, including previous health problems / surgeries; to current issues that includes the state of your health, diet and exercise routine. Our goal is to use this information to better understand you as an individual to create a partnership program to wellness.  

DO NOT WAIT UNTIL LAST MINUTE TO COMPLETE THE FORM AS THIS MAY TAKE 1-2 HOURS FOR THE OFFICE TO REVIEW IN ADVANCE. WE ASK THAT YOU RETURN THIS AT LEAST 48 HOURS PRIOR TO YOUR APPOINTMENT DATE.

We take this seriously and ask that you do.  Our providers are detectives at trying to find the root cause to your problems/symptoms to develop the best plan for wellness.

Pre-meeting with Practitioner:

Complete your intake material 48 hours prior to your appointment  Please bring and share with our staff your current supplements, prescriptions, and recent medical records (labs, x-rays, medical records, etc.).

Meeting with Practitioner:

During your consultation with our practitioner, this in-depth history will be reviewed to help provide us an overall picture of the state of your health. It may also help us to pinpoint the underlying causes preventing you from your optimal health today. The time spent with the practitioner during your consultation will take approximately 1-2 hours, which allows us to conduct a thorough initial evaluation.  

Your practitioner will discuss the reasons with you for your visit and work to identifying the root cause of your concerns. When the consultation is complete, your practitioner will explain their findings and propose an integrative wellness program that might best serve you.

Post-meeting with Practitioner:

When your practitioner visit is complete, the medical staff will discuss the proposed integrative wellness program with you.  This includes the steps towards partnering with you to support your prevention and wellness care.  Among items to be discussed will be follow-up visits, lab testing, supplements, scheduling and fees.  We will do all we can to assist you in moving smoothly through your integrative wellness program.  Our goal is to partner with you to meet your health goals

Attachments included with this Paperwork:

1. New Patient Registration and Authorization
2. Patient Email and Phone Message Authorization
3. Treatment Authorization and Medical Records Release
4. Health Questionnaire
5. Patient Finance Policy
6. Notice that Service is NOT Primary Care
7. Waiver/Release Communicable Diseases including COVID-19

* * * *

As a new patient, you have the option to return this form via word document, PDF (saved or scanned image), it can be faxed, or mailed to our office. Please be aware we use precautions to protect your privacy and information.  You can elect to send this back to us via your email but note this could be less secure.  Please keep a copy for your records and no cell phone screen shots.

Monarch Integrative Health 

ATTACHMENT 1

New Patient Registration and Authorization

GENERAL INFORMATION

EMERGENCY CONTACT

If you call MIH after hours, our staff will return your call on the next business day.  If you are experiencing a medical emergency, please call 911. MIH does not provide after hours communications with our 

If you call MIH after hours, our staff will return your call on the next business day.  If you are experiencing a medical emergency, please call 911. MIH does not provide afterhours communications with our practitioners. When leaving a voicemail message, please be brief and include the following: 1) Full Name, 2) Date of Birth, 3) Reason for the Call, 4) Best time to call back, and Phone Number(s).

Monarch Integrative Health 

ATTACHMENT 1 – continued, 

New Patient Registration and Authorization

Your health information is private and protected by law.  Your information will only be used or disclosed for giving care, billing, or supporting day to day operations.  You have the right to review your file at any time.  You may restrict all or part of your health information from being released, as allowable by law.  If you request information to be transmitted electronically, please be advised that your private information may not be protected and is NOT a company policy to do so. Monarch Integrative Health PLLC. transmits from a secure, encrypted network server, however, we cannot guarantee that any information you receive from us will be received through a secure network on your end. We will take every step necessary on our end to protect your privacy.  If you choose to contact us or your practitioner by electronic means, (i.e.: website, email, etc.), you understand that this is not a secured form of communication and you should NOT include private health information as it may not be protected, and by contacting us via those means, you are waiving your Privacy Rights. Monarch Integrative Health PLLC cannot guarantee your information remains protected during electronic communication.

The health information you provide during initial consultation and beyond is critical for the medical staff and practitioners to provide medical care and treatment.  It is important to provide full disclosure of past and current treatments provided by other providers. Our staff will work with you to understand how our integrative wellness program can best help you with the provided information.  You, the patient MUST disclose products, supplements, or treatments obtained outside of Monarch Integrative Health PLLC during medical care and treatment.  Monarch Integrative Health does NOT support products or services being purchased for use without consulting our office as this may affect the integrative wellness program you are on. It is the patient’s responsibility to inform our staff of any changes to patient paperwork (additional care, additional supplements, prescriptions, other practitioners, etc.) involved in wellness or care.

AUTHORIZATION TO PROVIDE MEDICAL CARE

All professional services rendered are charged to the patient (adults only). Information will be provided to the patient in advance and will be the responsibility of the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance with our office. Monarch Integrative Health PLLC. does not take or bill insurance providers, but in most cases, you can submit our clinic’s bill with codes provided for reimbursement.  Since we do not interact with insurance, it will be up to you to communicate with them.  Reimbursement from you provider depends on your health benefits plan.  You cannot submit your bill for Medicare reimbursement since our practice has opted out of Medicare.

I authorize Monarch Integrative Health, PLLC., to render medical care and treatment. I agree to be responsible for payment at time for services, supplements and medical care provided by our staff.  For labs/tests ordered and paid through Monarch Integrative Health, PLLC. as part of your prevention and wellness, you accept responsibility for payment.

I have read and accept my responsibilities under the ‘Attachment 1’ form and provided accurate information to the best of my ability

Monarch Integrative Health 

ATTACHMENT 2

Patient Email and Phone Message Authorization

I authorize Monarch Integrative Health (MIH) staff to leave private or confidential health information messages on my voice mail, or with whomever answers at the following telephone number(s).  Only select those that apply:  

Mobile Phone (personal)

Home Phone (personal)

Further, I authorize limited protected health information to be sent to the following e‐mail.  Information provided will be limited to scheduling dates/times, promotions, follow-up to basic questions, or requirements to disclose by law (federal, state, local guidelines).  This policy is to limit information being transmitted electronically that could impact patient privacy.

Primary Email (non-work, personal)

E‐mail communications are not encrypted, and while efforts are made to ensure privacy, confidentiality cannot be guaranteed, and patients are responsible for securing their part of the communication. The originating e‐mail address is not monitored and should not be used to send medical information or questions. 

I have read and accept my responsibilities under the ‘Attachment 2’ form and provided accurate information to the best of my ability

Monarch Integrative Health 

ATTACHMENT 3

Treatment Authorization and Medical Records Release

Treatment Authorization

by the staff at Monarch Integrative Health (MIH), and its partners affiliated with the practice.  The following patient will always inform staff of any medical treatment, services, or supplements that occurred in the past or during prevention and wellness care being provided.

Medical Records Release Authorization

I authorize Monarch Integrative Health to release my medical information to any physician or healthcare practitioner to whom I am being referred for care and to any payer of my care including managed care program, federal/state agencies upon their specific written request with your knowledge. Release of medical records takes time to consolidate patient information, there will $40.00 charge for each request.

I also authorize any physician, practitioner, or healthcare provider I have seen to release my medical records to Monarch Integrative Health.  Such authorization extends to records regarding my health and treatments.

Notice as to Nature of Service

I understand that care I receive at Monarch Integrative Health may be non-traditional or unconventional.  Such services are commonly referred to as complementary, alternative medical/medicine, holistic, integrative, or innovative services.  Because many of these efforts to resolve underlying difficulties in the body’s capacity to function, they are also known as functional medicine.  Many of these services may not be recognized as standard medical practice and may be considered investigational or experimental. Medications prescribed may or may not be approved by the FDA.

No Guarantees

I am aware that no practice of medicine is an exact science, and knowledge that there are and can be no guarantee as to accuracy or outcomes of my diagnoses or treatments I receive at Monarch Integrative Health.  I will provide reasonable efforts to educate the staff at Monarch Integrative Health about my history and condition to improve outcomes.

Monarch Integrative Health 

ATTACHMENT 4

ALLERGIES:

COMPLAINTS AND CONCERNS

What do you hope to achieve in your visit with us?

If you had a magic wand and could erase three problems what would they be?

Please list current and ongoing problems in order of priority:

Describe Problem and select a rating: Mild, Moderate, Severe

Share your Prior Treatment and select a rating: Excellent, Good, Fair

Weight/Height

MEDICAL HISTORY

Check appropriate and provide year of onset

GASTROINTESTINAL

Disease/Diagnosis/Condition

GENITIAL AND URINE SYSTEM

Disease/Diagnosis/Condition

CARDIOVASCULAR

Disease/Diagnosis/Condition

MUSCULOSKELETAL/PAIN

Disease/Diagnosis/Condition

INFLAMMATORY/AUTOIMUNE

Disease/Diagnosis/Condition

METABOLIC/ENDOCRINE

Disease/Diagnosis/Condition

RESPIRATORY

Disease/Diagnosis/Condition

SKIN DISEASES

Disease/Diagnosis/Condition

CANCER

Disease/Diagnosis/Condition

SURGERIES

Disease/Diagnosis/Condition

NEUROLOGICAL

Disease/Diagnosis/Condition

INJURIES

Mark all that apply, add date after the injury

PREVENTIVE TESTS AND DATE OF LAST TEST

HOSPITILIZATION

MEN'S HISTORY (for men only)

GYNECOLOGIC HISTORY (for women only)

Obstetric History

MENSTRUAL HISTORY

GI HISTORY

DENTAL HISTORY

MEDICATIONS

Current Medications

Previous Medications (last 10 years)

Nutritional Supplements (vitamins/minerals/herbs/homeopathy)

QUESTIONS

FAMILY HISTORY

SOCIAL HISTORY

SMOKING

ALCOHOL INTAKE

OTHER SUBSTANCES

EXERCISE

PHYCHOSOCIAL

STRESS/COPING

Daily stresses, rate on scale 1-10 (10 highest)

SLEEP / REST

ROLES / RELATIONSHIPS

How well have things been going for you (check the one that applies)?

.

ENVIRONMENTAL AND DETOXIFICATION ASSESSMENT

SYMPTOM REVIEW

Please check all symptoms present or last six months

READINESS ASSESSMENT

Rate on a scale of 1 (not willing) to 5 (very willing)

To improve your health, how willing are you to:

Monarch Integrative Health 

ATTACHMENT 5 – Patient Finance Policy

Monarch Integrative Health’s agreement is with YOU.  We are NOT associated with any insurance company or 3^rd party providers, which means insurance companies are not obligated to pay for services you receive at Monarch Integrative Health (consultations, therapies, treatments, labs, test, etc. as offered).  Our fees are posted on our website, and it is the patient’s responsibility to understand how they might impact any payment you will be asked to pay (www.monarchintegrativehealth.com ).

Our company requires payment at time of service and, if you choose, we will provide a receipt showing that you paid out of pocket.  WE WILL NOT, however, communicate in any way with your insurance companies or Health Saving Plans.  This is not a guarantee that those services provided will be paid for by your insurance company.  Many of the services provided at Monarch Integrative Health and/ or by our partners do not have medical billing codes.  For clients that have access to a Health Savings Account, some of your services may qualify for use with that program’s credit or debit card.

We have optimized our business practice to be a cash-based business.  We have found it allows our office to run more smoothly and allows us to be more financially stable. Monarch Integrative Health (MIH) expects payment for all consultations, therapies, treatments, labs, test, etc. to be paid at the time they are provided. MIH nor any third-party billers can predict or guarantee that any item or service will be covered.  Some of MIH services are considered non-covered by most insurance companies.  Patients are responsible for payment to MIH even if a service is non-covered or considered “not medically necessary” or “experimental”

Policies:

1. MIH accepts credit/debit cards for payment.  
2. MIH requires scheduling through their web site and all terms for cancellation, no show and credits are defined, they may vary depending on the Consult, Service or Product provided
3. Patient agrees to review scheduling policies at time they schedule their consult / service or purchase a product 
4. Patient acknowledges that their wellness plan could involve additional fees (supplements, laboratory testing, consults, services, etc.)  to confirm or test approaches to improving your health.  All fees shall be paid upon delivery and any future fees shall be discussed between patient and practitioner  

Insurance Information that may be used for labs or other services that might apply:

I have read and understand my financial responsibilities under the ‘Attachment 5’ form

Monarch Integrative Health 

ATTACHMENT 6 – Notice That Services Are NOT Primary Care

I understand that the staff at Monarch Integrative Health (MIH) will NOT be acting as my primary care physician. I understand that even though MIH staff may address issues affecting my general health, the practice is focused on services that are commonly referred to as complementary, alternative medical/medicine, holistic, integrative, or innovative and it is in my best interest to also have a primary care physician to ensure that I am fully appraised of all available conventional means to address any medical conditions I may have. This is also important because MIH practice is exclusively office-based and is 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. 

I also understand that it is my responsibility to inform Monarch Integrative Health who my primary care physician and specialists are, to let MIH know of any diagnoses I have received, and of any treatments I have had or am now undergoing for current conditions, and that I should keep MIH staff informed on an ongoing basis. 

I also understand that it is very important to let my primary care physician know about any treatments performed at MIH, to ensure that my care is safe and properly coordinated.

My Primary Care Physician / Doctor is:

Note: If you chose not to provide a primary care provider, you agree to not to make MIH your primary care provider and agree to identify a provider when needed or required 

I have read and understand my primary care responsibilities under the ‘Attachment 6’ form.