Please read the material below to familiarize yourself with our policies and procedures, and sign where indicated. We also ask that you visit our website at http://ccfmed.com/patients/become-a-patient/ to view our current procedures and fees. If you have any questions, contact us at (510) 849-6500 or send a Secure Message through your Patient Portal.

Authorization for Medical, Health and/or Nutrition Services: Pursuant to this Client Registration Agreement, I (hereafter, the words "I" and "me" include for myself and on behalf of my minor child) ackowledge that CCFM will not administer medical, health care and/or nutrition services, treatments and procedures to me directly. I understand that CCFM will instead be consulting to make recommendations about medical, health care and/or nutrition services that will be overseen by another clinician outside of CCFM. I understand that this consultation does not establish a clinician-patient relationship and that I should have a clinician overseeing my care outside of CCFM. I understand that CCFM may recommend an integrative program that may include conventional health care, nutritional therapies, functional medicine and other elements of integrative medicine.

I understand that if any explanations as to benefits and/or risks and dangers of the suggested treatments or services are unclear, it is my responsibility to ask for clarification of these recommendations from my treating clinician. I understand that there are no warranties, representations or assurances of successful outcomes. Nevertheless, I desire to pursue a consultation for these types of integrative medical treatment or nutrition services after reviewing the information herein and receiving answers to any questions related to this agreement. As a client seeking consultation for medical, health care and/or nutrition services, I understand that I am ultimately responsible for selecting and approving recommended treatments and services with a clinician outside of CCFM.

If a medical emergency arises, I will call 911 or visit the nearest hospital emergency room. I understand that CCFM is providing a consultation-only service. I understand that CCFM's consulting services do not substitute for primary medical care, and clients are expected to have a relationship with a primary medical doctor separate from CCFM.

I understand that CCFM is a medical corporation, organized and practicing under the laws of the State of California and that members of its clinical staff are licensed to practice their respective health care professions in California, and in no other jurisdictions, and practice only in California, pursuant to the laws, regulations and standards of practice of the State of California. I am aware that clients serviced by telecommunication, or other electronic modality, are receiving consultation only services in the State of California, and not in any other jurisdiction. I agree that any disputes concerning the rendering of services will be subject to the laws, regulations and standards of practice of the State of California, and any suit against CCFM must be brought in California, pursuant to the Agreement for Arbitration between CCFM and its client.

Risks, Benefits, and Alternatives of Treatment: I understand that in general, integrative, functional and traditional medicine provide benefits that include relief of presenting symptoms and improved function that may lead to prevention, improvement or elimination of the presenting symptoms, though no particular outcome can be warrantied or guaranteed. I further understand that like with any health treatment, such treatment is not without risk, and that potential risks of treatment include allergic reactions, sensitivities, adverse effects from, or in response to, natural supplements or dietary measures, failure to improve or worsening of the client's condition and difficult adjustments to making lifestyle modifications. I am aware that other side effects and risks may occur. I agree to inform CCFM clinical staff of all known factors which might affect treatment, including all medications, drugs, drug sensitivities and allergies, history of seizures, fits or fainting, presence of a pacemaker, bleeding disorder, use of anticoagulants, damaged heart valves or occluded vessels, immune deficiencies or other special risk of infection, as well as any other significant factors. I also agree to inform CCFM clinical staff of any disorder, or state of mind, that might affect my capacity to make informed health decisions, and should any such impairment exist, I will provide information regarding a surrogate decision maker.

I understand that an explanation of the risks, benefits and alternatives of any specific procedures or treatments, recommended or undertaken, will be provided to me at the time of discussion of such recommendations with my treating clinician and will not be provided by CCFM.

I agree to immediately inform my treating clinician of any adverse effect of treatment noted, including any unanticipated pain or other negative sensation, unpleasant cognitive conditions, anxiety, depression or other negative emotions or any unpleasant taste or smell associated with the consumption of supplements or herbs. I will immediately notify the my treating clinician in the event of pregnancy, or suspicion of pregnancy, as some treatments may be contraindicated in the event of pregnancy.

I agree that I have read and understood the information contained in this part, entitled "Risks, Benefits and Alternatives to Treatment." In consideration of the consultation services to be performed and products obtained, I agree to be bound by the terms of this agreement.

Appointments and Cancellation Policy: I understand that my appointment time with CCFM is reserved exclusively for my consultation for the duration of all scheduled appointments. I understand that I am expected to keep all appointments, as scheduled, and that if I am late for an appointment, the appointment will end at the scheduled time and I will be responsible for the cost of the full appointment. If I need to cancel or reschedule an appointment, I will cancel the appointment using the Appointments tab in the Patient Portal. I understand the cancellation policy as follows:

Consult appointments:
I understand that appointments must be cancelled or rescheduled at least 48 hours prior to the scheduled appointment or cancellation fees will apply. I agree that cancellation fees will equal 50% of the appointment fee for the first late cancellation and 100% of the appointment fee for subsequent late cancellations.

Telephone and Electronic Messaging Policy: I am aware that CCFM checks telephone messages and Secure Messages during business hours and responds to them on a regular basis throughout the week. I will allow up to 3 working days for a response and will not send urgent messages. If my questions and/or concerns are more complex, I understand that a follow-up appointment may be requested, and I will be responsible for the standard follow-up fees, which will be charged to the credit card on file. If I am experiencing a medical emergency, I will call 911 or go directly to an emergency room. By sending a Secure Message, I acknowledge and agree that a prompt reply is NOT required or expected, and that I will not use Secure Messages to deal with emergencies or other time-sensitive issues. I also understand and agree that email communications (outside of the secure Patient Portal) may not be secure and the confidentiality of emails cannot be assured or guaranteed. I therefore take the risk that all email communications may not be confidential. I understand that CCFM may keep copies of email and Portal communications, and that such messages may be included in my health record.

Insurance Responsibility and Claims Management: I acknowledge that it is my responsibility to know my insurance plan benefits and to obtain insurance advice as to what health charges may be covered from my own licensed insurance agent, broker or human resource professional. Given the uncertainty that pervades insurance decisions, I agree that CCFM is not responsible for the accuracy of any information related to my insurance. I agree that, though CCFM may reasonably assist me with insurance submissions, it is not obligated to advocate or take action on my behalf against any insurance company related to any insurance claim or payment. I understand that I will receive a superbill/insurance invoice showing the cost and nature of services and it will be my responsibility to submit the claim to the insurer. I understand that CCFM will reasonably assist me, when feasible, with documentation for submission for possible reimbursement, but is not responsible for speaking to the insurance company on my behalf.

I understand that CCFM does not participate in insurance plans or accept assignment from any other payer including employers or insurers. I will be responsible for all charges and fees incurred for treatments or services rendered, whether covered or not by my insurance company, Medicare or Medicaid, or any other health plan. I understand that insurance reimbursement may not be available for some services. By way of example, I acknowledge that I have been informed that my insurer may not pay for office visits, telephone or video consultations, or emails, including, but not limited to, circumstances where the focus of the consultation is on prevention, education, wellness, nutrition advice, or herbal medicine. I also understand that some of the lab tests that are recommended, particularly those that are used in support of wellness consultations or are kits sent to labs using innovative approaches to diagnostics, may not be reimbursed.

Financial Responsibility and Authorization for Payment: I understand that payment for all services, treatments, products and other fees will be required at each appointment and after each other service related matter, and I authorize CCFM to charge all outstanding balances to my credit card on file. I authorize this credit card to be used to guarantee and pay for late cancellations, missed appointments, and unpaid balances, including those related to appointments, telephone and electronic consultations, charges for products and supplements, and miscellaneous costs. I agree that if for any reason the credit card on file does not accept the charge, I will immediately make payment to CCFM for the amount due and will provide alternative credit card information upon request.

Refund Policy:

Supplements: I understand that unopened supplements are eligible for a full refund, minus shipping costs and administrative/restocking fees (if charged by the supplement vendor), within the timeframe allowed by the supplement vendor, and I am aware that CCFM cannot issue a refund for supplements that have been opened, or in cases where the supplement vendor deems the supplement non-refundable.

Health Information Release Authorization and Privacy Practices: I understand that CCFM is permitted by applicable federal and state privacy laws to use and disclose my protected health information (PHI) for treatment, payment and health care operations and for other purposes as required or permitted by law. I am aware that the CCFM Notice of Privacy Practices, as it may be amended from time to time , is available upon request. I authorize CCFM to release my medical records in connection with treatment, payment for services and its health care operations and as provided in the Notice, which is incorporated into this Agreement by reference. I understand that the Notice may be modified or amended on the basis described in the Notice. I understand that if I choose to pursue a chargeback through my credit card company for any charges for appointments that I have completed or testing/supplement charges that I have approved, or otherwise accrue an unpaid balance, I forfeit my right to privacy and the information required to pursue collection and/or legal action will be disclosed in seeking remuneration. If I do pursue a chargeback, I understand that I will be charged a reasonable administration fee for charges associated with CCFM disputing the action.

Complaints, Comments and Questions: I understand that CCFM is committed to providing quality care and resolving favorably any complaint, problem, question or unsatisfactory experience that might occur in connection with consultation services, and that it is the policy of CCFM that (i) if any person has a complaint or problem or unsatisfactory or negative experience related to our business, services or products, such person must bring the matter to the attention of CCFM privately, by email, phone or in person; and (ii) CCFM will investigate any such matter and attempt in good faith, without any retaliation, to reasonably resolve the matter.

By registering, I agree to comply fully with this policy, and I understand that, other than arbitration, to which I have agreed in the separate Clinician-Client Arbitration Agreement, this is my sole and exclusive remedy in connection with any complaint, problem, or unsatisfactory or negative experience that I may have with CCFM, services or products. I further agree not to publish, post, transmit, disclose or distribute (directly or indirectly), in or on any publicly available or accessible forum, newspaper, magazine, electronic publication, blog, website, online users group or similar device, document or medium, any negative, false or disparaging comment, belief, opinion, experience or information, without prior written consent. I acknowledge and agree that these terms are reasonable and that any breach or violation of this paragraph will cause significant damage and expense that would be impossible or highly impractical to quantify and establish. Consequently, I agree that upon each breach or violation of this paragraph, I will be obligated to pay liquidated damages in the amount of $200.00 per day per violation until the breach or violation has been cured to the satisfaction of CCFM.

Duration of Agreement, Revocations of Authorizations and Amendments: I understand that I may revoke the medical records release authorization in writing at any time and CCFM will attempt to accommodate all reasonable requests. However, I understand that in some circumstances related to treatment, payment, or health care operations, CCFM may not be able to accommodate such requests. I further agree that, in no event, will any revocation of a prior authorization affect any of my other obligations under this agreement. I agree that the rights and obligations of the parties herein shall be fully applicable and the respective rights and obligations of the parties shall survive expiration, cancellation or termination of this agreement for any reason. I also certify that I am enrolled in this practice to receive medical and health care and for no other purpose. I agree that this agreement and the notice, along with my Clinician-Client Arbitration Agreement, constitute the entire and exclusive agreement between CCFM and me and supersedes any prior or other contemporaneous agreement. I agree that this agreement may only be amended by a written document signed by CCFM and the registering client or client's legal advocate.