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A hard copy of this will be presented for e-signature upon enrollment

Sanctuary Functional Medicine DBA, LLC

120 Holiday Court, Suite 2

Franklin, TN  37067

 

Contract for Immune Prepper Bootcamp

                                                                          

This is a covenant and agreement between Sanctuary Functional Medicine DBA, PLLC (treatment program) and _______________________________ (You/patient).

 

Dr. Eric Potter (physician) and  other providers who specialize in functional medicine, internal medicine, family medicine and pediatrics, deliver health care treatment programs on behalf of Sanctuary Functional Medicine.  In exchange for certain fees paid by You as described below, Sanctuary Functional Medicine agrees and contracts with you to provide the treatment program services via Physician or Physician Assistant or Nurse Practitioner.

 

 OUR SERVICES TO YOU

 

Your initial payment of:  _______ $1500 when paid in full at contract signing

                                                 _______$1250 discounted for November Launch

 

            Discounts:    _____ Labs not included ($850 payment)

_____ Additional child(ren) with labs ($1050 each) x ____ #

 

  • You will receive questionnaires and forms to complete prior to your Physical Exam with our Nurse Practitioner. Please complete no later than 2 weeks prior to first visit.  If not completed 2 weeks prior to first visit we reserve the right to cancel and reschedule your appointment.
    • Paperwork required:
      1. MDHQ Questionnaire.
      2. HIPAA Privacy and Consent agreement
  • Medicare Opt –Out acknowledgement form
  1. Patient demographics form
  2. Lab Consent form
  3. Other forms as instructed

 

  • Lab draw and coordination:            
    • Lab draw fees and coordination at our office are included for the initial visit.
    • If labs are performed elsewhere, there will be additional $50 coordination fee.
    • Additional lab draw/coordination beyond the first two visits/draws will be an additional cost of $25 per lab draw PLUS cost of labs.
    • The costs of listed lab tests ARE included in the treatment program. Other labs will be an additional cost.  
    • Included Bonus Labs
      1. Complete Blood Count
      2. ESR – inflammation
  • High Sensitivity CRP – inflammation
  1. Zinc
  2. Copper
  3. EKG to determine safety of high dose azithromycin therapy
  • Vitamin D 25 Hydroxy
  • Inclusion of 1 advanced labs determine by clinician judgment
    1. Blood Heavy Metals test OR
    2. Urine Synthetic Toxins test OR
  • Food IgG testing OR
  1. Environmental allergens IgE
  • Immune Prepper Video course access
  • Question and Answer session date __pending____ 90 minutes
  • Physical exam by SFM Nurse Practitioner during first 2 weeks of December
  • Lab draw after Physical exam
  • Group lab review Mid December reviewing lab results by zoom in a group
  • Group follow up 3 months later (Mid April) to assess progress
  • Access to supplement recommendations and immune prescriptions 8am to 5pm for the cost of additional clinician visits.
  • Access to SFM IV program for Vitamin C, B vitamins, glutathione or other medically appropriate therapies at clinic rates.
  • Coupon bundle.

 

COVERS 6monts and then need FOLLOW UP.  Does not include:

  • Portal Access to Sanctuary Staff
  • Primary care services beyond immune/infection related issues.

 

The following are optional and can be purchased with the package above:

  1. IV Therapy sessions – price depends on therapy utilized.
  2. Sauna Packages when available

 

Total time covered: estimated completion of program is 6 months.                                                                                                                                Initials: __________

 

Your Initial fee is 100% refundable up until release of video course.  At that point a refund of $1000 is available until labs are performed.           Initials: __________

 

Lab draws, coordination with outside labs AFTER initial lab draw are 

$25 each additional lab draw.                                        Initials: __________

 

  • You agree that to maintain services of Sanctuary Functional Medicine, you will need to be seen in person a minimum of every 12 months and have a video visit every 6 months.  You also understand and agree that Sanctuary providers are not primary care providers and you should have a primary care provider to assist you as needed.

                                                                                               Initials: _______________

 

Initial   Visit:

Your first visit will be approximately 1 hours between the clinician, nursing, and lab draw. At this time, your provider will complete a physical exam before team performs lab draw.

 

 

Additional Follow up visit OR Extended Visit Times are NOT included in the package and are priced as follows:

When additional visits or follow up visits are determined to be necessary or requested by the patient/patient family (beyond those included in treatment plan) or the patient does not extend their program beyond the initial plan those visits will be charged as follows:

  • Fees for visits are based on time and practitioner. If you are scheduled for a 25 minute visit and it takes longer than 25 minutes for the appointment you will be charged accordingly.  Visit fees are based on time spent, not on the time slot length of appointment.
    • Visits with Dr. Potter are $280 per 25 minutes
      • Visits extending beyond scheduled time will be charged accordingly.
      • Example: a 25 minute visit that lasts over 35 minutes would be charged additional $140.
      • Example: a 40 minute visit that lasts over 50 minutes would be charged an additional $140.
    • Visits with the physician assistant or nurse practitioner are $230 per 25 minutes
      • Visits extending beyond scheduled time will be charged accordingly.
      • Example: a 25 minute visit that lasts over 35 minutes will be charged additional $115.
      • Example: a 40 minute visit that lasts over 50 minutes would be charged an additional $115.

 

 

These may include phone appointments or face to face visits and in certain instances telemedicine visits.

Initials: ___________

 

 

Labs and Supplements:

The cost of labs ordered (beyond the noted included bonus labs) by Sanctuary or medications/supplements ordered by Sanctuary are NOT

included in the rates above, but are paid per service/product rendered.  Payments for the services are required at time of service/product being rendered.    Once patient ends care with office, these prices are no longer available.  If a patient has not seen a Sanctuary provider for over 6 months, discounts end.

 

Lab draw fees are included for the initial visit only.  Additional lab draws will be charged at $25 per lab draw.

 

Payment of half the estimated cost of additional lab testing is due at the time of service. We will make every reasonable effort to ensure the estimate is as close to the expected final cost as possible.

Payment in full is expected on all services except lab services at the time of service.  Lab balances are to be paid in full within 30 days of posting the final charges.

Initials: ________________

 

 

NOTICE

 

 

Cancellations and “no shows”:

Because of the financial impact cancellations and missed appointments have on the consultant, there will be a fee for appointments not kept without a 72-hour notice.

 

 

For re-scheduling initial physical exam the fee is $100.   The required notice is 48 hours with Monday appointments requiring a Friday notice by Noon.

 

Lab draw appointments require a 24 hour notice to reschedule.  Monday appointments require notice no later than NOON on Friday.  Late notice of cancellation will be charged $25.

                                                                                   

                        Initials: __________

 

Refunds:

For paid treatment programs, the refund policy after the first visit is as follows minus any of the options exercised.

For Full Pre-paid program

Full refund of initial payment until release of Video course for viewing.

$1000 refund available from time of video course release to Lab draw

After lab draw $400 refund available.

If a refund is requested, it will be provided by check or via online processing within 14 business days. We are not responsible for delays that occur due to digital/online refunds.

 

Dismissals from the practice:

If you are dismissed from our practice for any of the below noted reasons, you will receive a refund according to the Refund policy noted above.

Reasons include but are not limited to:  1) Inappropriate behavior or language directed at any Sanctuary staff.  2)  Any threats against clinic or staff.  3)  Failure to pay balance over $100 for period of 6 months unless payment plan approved.

In the event of dismissal, you will receive a letter notifying you that you have 30 days to locate another physician.  Emergency care only will be provided by our staff during those 30 days.  We will transfer records to the new physician by fax or to you by the portal upon receipt of a release of information form.

Any unpaid balances will be deducted from the refund.

Initials: __________

 

Medicare:

This agreement is entered into with the full understanding of You that our Physicians/Clinicians are opted-out of Medicare.  Therefore, Medicare dictates that they cannot be billed for services performed for You (if applicable).  You agree NOT to bill Medicare or submit claims to Medicare for reimbursement for Physician services (For more details please see separate Medicare opt out form).

Please initial here your understanding that we are opted out of Medicare.      

                                                                                                                  Initials: __________

 

 

Insurance:

Sanctuary Functional Medicine does not accept insurance and our clinicians are not enrolled with any insurance plans.  Invoices will be provided if you desire to submit the charges to your insurance company to request reimbursement.  Sanctuary Functional Medicine does not guarantee that services will be covered by insurance or other reimbursement plans. Clinicians at Sanctuary Functional Medicine are out of network providers.  We encourage and recommend that you contact your insurance company regarding out of network clinical services including lab services.               Initials: _____________

 

Late Payment.

Please notify us of credit card or debit card changes promptly. It is ultimately patient responsibility to update any card change information prior to the monthly fee being charged. A $20 fee will be charged for payments that are late beyond 15 days of the due date (i.e. normally paid on 15th would mean we would expect an update before the 30th                                                             Initials: __________

 

 

 

Amendment. No amendment of this agreement shall be binding on a party unless it is made in writing and signed by all parties.

 

Entire Agreement. This agreement contains the entire agreement between parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this agreement.

 

Jurisdiction. This agreement shall be governed and construed under the laws of the State of Tennessee. All disputes arising out of this Agreement shall be settles in the court of proper venue and jurisdiction for Sanctuary Functional Medicine DBA, LLC in Nashville, Tennessee.

 

Patient communication via portal, email, or phone– The patient portal is used to upload documents, forms, test results, etc. as well as to making simple inquiries on an order. If you have any questions that require clarification or a prolonged answer from Dr. Potter or clinic staff, please call to schedule a time via phone to discuss. Please note, portal communication has a limit on the length of message you can send/write to us.

 

Communication directly to the email address provided by you to Sanctuary Functional Medicine may be occasionally used to notify you of upcoming events, general practice announcements, as well as to send you newsletters and blogs. If you do not want to receive this type of communications, you can opt out of those via the email unsubscribe reporting notice.

 

Please note that for treatment program patients, a phone visit with Dr. Potter or Leslie Mullins or other Provider is the same as an office visit and charges will be made accordingly.

 

 

ELECTRONICALLY SIGNED                                     DATE OF ELECTRONIC DELIVERY

_________________________________________                          ___________________________

Signature of Dr. Potter for                                           Date

Sanctuary Functional Medicine DBA, PLLC

 

 

_________________________________________                         ____________________________

Signature of Patient                                                    Date

 

 

_________________________________________

Name of Patient (printed)