Cancelation and rebooking policy
In order to reserve your time, all appointments are prepaid at the time of booking. If for any reason you cannot make your appointment, please let us know at least 48 hours before your scheduled time, so we can reschedule accordingly. New client paperwork requires at least 48 hours to complete and review, and returning clients typically schedule weeks in advance. Therefore, we are not able to reschedule with short notice in most instances and would otherwise lose income when a client no-shows or late cancels an appointment. Missed appointments will be refunded at 50% of the prepaid rate.
Late policy
Kristin will wait 15 minutes on the platform for our scheduled appointment. If you arrive in that time, the visit will commence, but our end time remains as scheduled. For example, if we are scheduled to meet from 1pm-2pm, and you log in to our meeting at 110pm, we will have fifty minutes to meet. No partial refunds will be provided for visits started late, as Kristin will be present the entire scheduled time.
informed consent
INFORMED CONSENT
[NAME OF PATIENT] (hereinafter “I”) seek the medical services of St Jean Functional Health, PLLC (“Practice”). I am executing this informed consent document (“Informed Consent”) to verify and confirm my discussion with Kristin St Jean, RN (“Provider”) regarding the risks, benefits, and alternatives to treatment through Practice. I am here for my own purposes and not on behalf of any third-party. I understand that I am a participant in the decision-making process and I am free to decline services or treatments at any time. I agree to bring to the attention of Practice’s clinical staff, if, at any time, I have any lack of understanding of such risks, benefits and alternatives, and inquire of clinical staff for further explanation until I have a full understanding before giving consent to any procedure or treatment.
1. Benefits of the functional medicine approach and scope of practice
I understand that Provider and his/her team use diagnostic and treatment methods that—in addition to conventional health care—are known as preventative, complementary, alternative, functional, naturopathic, or integrative medicine (collectively, “Functional Medicine”). In general, Functional Medicine may 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. Functional Medicine focuses on nutritional and metabolic imbalances, diet, exercise, environmental influences, and psycho-social stressors based on the premise that they directly relate to the development and maintenance of illness. Functional Medicine evaluates these influences and then specifically tries to remedy them. It encourages patients to give up negative lifestyle patterns and establish more positive ones, regardless of the type of medical conditions for which they are seeking treatment.
2. Risks
I understand that, as with any health treatment, Functional Medicine is not without risk. Potential risks of treatment include, but are not limited to, allergic reactions, sensitivities, adverse effects from, or in response to, natural supplements or dietary measures, failure to improve or worsening of my condition, and difficulty adjusting to lifestyle modifications. Other side effects and risks may occur.
I agree to inform Practice’s clinical staff of all known factors that might affect treatment, including, but not limited to, all medications, drugs, drug sensitivities and allergies, history of seizures, fits or fainting, presence of a pacemaker, bleeding disorder, use of anti-coagulants, damaged heart valves or occluded vessels, immune deficiencies, or other special risks of infection, as well as any other significant factors within my knowledge. I further agree to inform Practice’s 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 Functional Medicine may be different than what some people consider “mainstream” medicine.” I am aware that there is some controversy in the medical community as to integrative or functional medical practices. Some of the potential “risks” of Functional Medicine that are asserted by critics in this debate are:
a. lack of sufficient testing to constitute “evidence-based” medicine;
b. use of biologically active agents that can present risks when used in conjunction with conventional medical therapies;
c. potentially negative biological or psychological effects that have received insufficient testing;
d. delay in seeking mainstream treatment based on scientifically unsupported practices; and
e. use of laboratory tests, the value of which other practitioners question.
I understand that, despite this debate, Provider and/or Practice only employs treatments Provider believes, based on his/her training, experience, evidence-backed studies, and current research, to be safe and effective, and Provider will alert me to the risks and benefits of any treatments before they are administered.
3. Alternatives and Responsibility to Maintain Separate Primary Care Physician
The intent of any and all services offered and/or nutritional protocols or lifestyle recommendations suggested by Kristin St Jean, RN is designed to support the natural physiological & biochemical processes of the human body. Kristin St Jean, RN is not a medical doctor. The purpose is not to diagnose, treat, prevent or cure any disease. All suggested protocols are from a holistic health perspective. As alternatives, Provider encourages me to speak with and consider the advice of other Providers, including conventional or mainstream physicians and providers. Provider will consult with, but does not replace, care currently provided to me by other physicians or providers, such as my internist, gynecologist, cardiologist, gastroenterologist, pediatrician (in the case of children), oncologist or other specialty care provider. In addition to discussing other modes of therapy that may be used for the treatment of my condition, Provider and I have discussed, and I understand, the possibility of a referral to a specialist for my condition(s) if I have not already consulted with an appropriate specialist. Provider has advised me that he/she does not admit patients to the hospital or treat hospitalized patients.
I understand that as a condition of my treatment by Practice, I must maintain a relationship with an outside physician to act as my primary care provider and to provide emergency and urgent care. If I encounter a medical emergency and am not able to obtain care from my primary care physician(s), I will contact 911 or report to a hospital emergency department as appropriate.
4. Medication and Responsibilities
I understand that Practice may make available nutritional supplements and other products for sale to patients in its office and on its website. I understand that I am not obligated to purchase these products from Practice, and I can purchase medications, dietary supplements, and other products from any source of my choosing.
I understand that, as with any health treatment, there is no guarantee that I will obtain satisfactory results. If I am being treated for a medical condition, or have symptoms that suggest a medical condition may be present, I have been informed that it is in my best interest to discuss potential alternative methods of treatment for my condition with my primary care physician or an appropriate specialist before, as well as during, the course of treatments. I understand the services provided by Practice do not preclude me from using other treatments as well, though I recognize that I should inform any practitioners I am seeing about the various treatments I am using. I understand that my failure to comply with any treatment recommendations will have an impact on the results of treatment.
I understand that I must immediately inform Practice’s clinical staff 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 Practice’s clinical staff in the event of pregnancy or breastfeeding, as some treatments may be contraindicated for pregnant or breastfeeding patients.
I understand that I am responsible for disclosing to Provider all medications, care, and assessments that I receive elsewhere and to provide medical records from other providers to ensure that care is coordinated and compatible. Likewise, I am responsible for informing any other health professionals of the treatments, supplements, and/or medications I undergo with Provider and/or Practice.
I understand that Provider’s treatment may include the recommendation that I seek other types of treatment from other health professionals who are not affiliated with Practice. I understand that while Provider may communicate with these professionals to explain why Provider made the recommendation, Provider does not supervise them and is not responsible for them.
I understand that Practice does not accept insurance and I agree that I am financially responsible for the services rendered. I understand that insurance companies are likely to consider Functional Medicine to be non-covered or to deny claims for Functional Medicine as non-standard care, preventative care, or as not medically necessary. I understand that Practice may provide me with a receipt for services called a “superbill.” I understand that I may submit this superbill to my insurance company or any third-party payor, including any government payors, for any services rendered by Practice. I understand that I may not receive full reimbursement or any reimbursement at all from these third-party payors. I also understand that if I am, or during the course of my relationship with Practice, become an eligible Medicare Beneficiary, then I will be given notice of Practice’s status with respect to Medicare and that I will be given separate notice about my financial responsibilities as they relate to Medicare.
NOTE: Do not sign this form unless you have read it and feel that you understand it. Ask any questions you might have before signing this form. Do not sign this form if you have taken medications which may impair your mental abilities or if you feel rushed or under pressure.
By signing below, I acknowledge and certify that I have had opportunities to ask questions and have had them answered to my satisfaction; I have read and fully understand the foregoing Informed Consent, and I have all of the knowledge I currently desire; I have discussed the issues noted above with Provider; and I agree and accept all of the terms above. I am legally competent and have sufficient knowledge to give voluntary and informed consent.
PATIENT
SIGNATURE: ______________________________
PRINT NAME: ______________________________
TITLE (if legal representative or guardian): ___________________
DATE: __________________________
I have explained this Informed Consent and answered all questions in layman’s terms, and informed the patient of the available alternatives and of the potential risks. To the best of my knowledge, the patient has been adequately informed, comprehends the information, and has consented.
PRACTICE
SIGNATURE: _______________________________
PRINT NAME: _______________________________
DATE: __________________________
fee for service agreement
St Jean Functional Health, PLLC
FEE-FOR-SERVICE AGREEMENT
THIS FEE-FOR-SERVICE AGREEMENT (“Agreement”) is entered into on______________, 20____, (“Effective Date”) by and between St Jean Functional Health, PLLC, located at Dover, NH (“Practice”), and [NAME OF PATIENT] (“Patient”). Practice and Patient may be referred to herein collectively as the “Parties” or individually as a “Party.”
RECITALS
WHEREAS, Practice provides functional medical services and delivers personalized care, as enumerated in Attachment A, Fee Schedule, incorporated herein by reference; and
WHEREAS, Patient, according to the terms of this Agreement, desires to contract with Practice to obtain such services and care.
NOW, THEREFORE, in consideration of the foregoing recitals, which are incorporated as covenants, and the mutual promises herein made and exchanged, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows:
AGREEMENT
1. Definitions. Throughout this Agreement, the following terms shall have the following meanings:
(a) “Practice” shall mean St Jean Functional Health, PLLC, together with any and all of its medical practitioners.
(b) “Patient” shall mean the individual (or individuals) specifically listed above and documented on the appropriate Client Intake Form(s). If one or more minors, incapacitated persons or persons subject to a power of attorney are documented on the appropriate client intake form(s), “Patient” shall include, jointly and severally, the parent, legal guardian, or surrogate decision maker of the Patient.
(c) “Services” shall mean those services specifically enumerated in Attachment A and shall exclude any and all other services not specifically enumerated, including, but not limited to, specialized services, emergency services, prescriptions, supplements, lab work, x-rays, ultrasound, MRI or those services Practice is not equipped, licensed or otherwise capable of providing.
2. Fees. In consideration for the Services provided, Patient agrees to pay Practice the amount(s) as set forth in Attachment A. This fee is due at the time Services are rendered. The Parties agree that the fee payable herein is fair market value for the specific Services rendered. Practice reserves the right to discontinue providing Services to Patient upon Patient’s failure to pay any fees pursuant to this Agreement.
3. Collections Policy. In the event of nonpayment, Practice reserves the right to turn your account over to a collection agency or attorney in order to obtain payment of fees owed.
4. Non-Participation in Insurance. Patient understands and acknowledges that Practice does NOT participate in any private or government funded health insurance, PPO or HMO plans or panels and has opted-out of Medicare. Patient shall not submit bills to any government or private insurer or federal or state health care program (including Medicare, Medicaid, Tri-Care, Veterans Affairs, Federal Employee Health Benefits, etc.) for Services even if deemed to be a covered service under such third-party insurance plan, and acknowledges that neither Practice nor its professionals will bill any third-party health insurance plan for the Services provided to Patient. Patient shall, therefore, remain fully and completely responsible for payment to Practice. Practice does not make any representation or warranty whatsoever that any fees paid under this Agreement are covered by Patient’s health insurance or other third-party payment plans applicable to the Patient. Patient hereby represents and warrants that Practice has advised Patient to either obtain or keep in full force such health insurance policy(ies) or plan(s) that will cover Patient for general health care costs. Patient acknowledges that this Agreement does not cover hospital services, or any services not personally provided by Practice.
5. Private Contract. If Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient agrees to sign a Private Contract in the form designated by Practice. To the extent required by law, Patient agrees to enter into a renewed Private Contract every two (2) years, as requested by Practice.
6. Communications. Patient understands and agrees that e-mail communications (outside of the secure patient portal), facsimile, video chat, instant messaging, and cell phone are not guaranteed to be encrypted, secure or confidential methods of communications. Patient agrees that any communications made outside of the patient portal are made at Patient’s risk with respect to all e-mail communications. Patient understands that use of electronic communication outside of the secure patient portal has inherent limitations, including possible breach of privacy or confidentiality, difficulty in validating the identity of the parties, and possible delays in response.
Practice will not respond to e-mails or other messages that contain sensitive medical information. If a response is requested, Practice will respond through the secure patient portal. Though it is Practice’s policy only to respond through the patient portal, by initiating correspondence through an unsecure and/or unencrypted channel, Patient hereby expressly waives Practice’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. Patient understands and acknowledges that Practice may retain any communications between Practice and Patient and include such communications in Patient’s medical record.
Patient understands and agrees that portal messaging or e-mail are not appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation which Patient reasonably believes could develop into an emergency, Patient shall call 911 or proceed to the nearest emergency room, and follow the directions of emergency personnel.
Practice checks telephone and portal messages during business hours and responds to them on a regular basis throughout the week. Portal messages are to be used for non-urgent messages only, and a response will generally be sent within 2 business days. By leaving a telephone or portal message, Patient acknowledges and agrees that a prompt reply is NOT required or expected and acknowledges that Patient will not use portal messages to deal with emergencies or other time sensitive issues.
Practice expressly disclaims any liability associated with any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of any action, inaction, technical issues, or activity outside Practice’s control, including but not limited to, (i) technical failures attributable to any Internet service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address portal messages, (iii) failure of Practice’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of e-mail communications by a third-party; or (v) Patient’s failure to comply with the guidelines regarding use of e-mail communications set forth in this Section.
7. Practice is not Primary Care Provider. Practice’s medical practitioners are not Patient’s primary care physicians. Patient is required to have a separate primary care physician on file with Practice. If Patient encounters a medical emergency and is not able to obtain care from Patient’s primary care physician(s), Patient shall contact 911 or report to a hospital emergency department as appropriate.
8. Change of Law. If there is a change of any law, regulation or rule, federal, state or local, (“Applicable Law”) which affects this Agreement, or the duties or obligations of either Party under this Agreement, or any change in the judicial or administrative interpretation of any such Applicable Law, and Patient reasonably believes in good faith that the change will have a substantial adverse effect on his/her rights, obligations or operations associated with this Agreement, then Patient may, upon written notice, require Practice to enter into good faith negotiations to renegotiate the terms of this Agreement. If the Parties are unable to reach an agreement concerning the modification of this Agreement within forty-five (45) days after the date of the effective date of change, then either Party may immediately terminate this Agreement by written notice to the other Party.
9. Severability. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of this Agreement shall not be affected. Any invalid or unenforceable provision shall be modified to the minimum extent necessary so as to remove the basis for invalidity or unenforceability.
10. Amendment. No amendment of this Agreement shall be binding on Practice unless it is made in writing and signed by Practice. Practice may unilaterally amend this Agreement, to the extent permitted by Applicable Law, by sending Patient a thirty (30) day advance written notice of any such change. Any such changes are hereby incorporated by reference into this Agreement without the need for signature of Patient and are effective as of the date established by Practice, except that Patient shall initial any such change upon Practice’s request. Moreover, if Applicable Law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.
11. Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient. Practice may assign this Agreement in whole or in part provided Practice provides Patient with written notice of such assignment. To the extent Practice assigns this Agreement in whole or in part, the transferee or assignee shall enjoy and undertake the same rights and obligations herein as Practice has hereunder to the extent incorporated in such assignment.
12. Relationship of Parties. Patient and Practice intend and agree that Practice, in performing Services pursuant to this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and the United States Department of Labor, and Practice shall have complete control over the manner in which the Services are performed.
13. Legal Significance. Patient understands and acknowledges that this Agreement is a legal document that creates certain rights and responsibilities. Patient represents and warrants that he/she has had reasonable time to seek legal advice regarding this Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of this Agreement.
14. Force Majeure. Neither Party shall be liable to the other for the failure or delay in the performance of any of the obligations under this Agreement when such failure or delay is due, directly or indirectly, to any act of God, acts of civil or military authority, acts of public enemy, terrorism, fire, flood, strike, riots, wars, embargoes, governmental laws, orders or regulations, storms or other similar or different contingencies beyond the reasonable control of the respective Parties.
15. Miscellaneous. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the Party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
16. Entire Agreement. This Agreement contains the entire agreement between the Parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.
17. Notice. All written notices are deemed received by Practice if sent to the address of Practice written above and by Patient if sent to the Patient’s address appearing in the applicable client intake form(s), provided notice to either Party is sent by Certified U.S. Mail, Return Receipt Requested. If Patient changes his/her address, Patient shall notify Practice promptly of his/her change of address.
18. Governing Law; Venue; Waiver of Jury Trial. Any controversy or claim arising out of or relating to this Agreement, or the breach thereof, shall be settled by binding arbitration. The demand for arbitration shall be made within a reasonable time after the claim, dispute or other matter in question has arisen, and in no event shall it be made more than two (2) years from when the aggrieved Party knew or should have known of the controversy, claim or dispute. The number of arbitrators shall be one. If the Parties are unable to agree upon the selection of an arbitrator within twenty-one (21) days of commencement of the arbitration proceeding by service of a demand for arbitration, the arbitrator shall be selected by the American Arbitration Association. The place of arbitration shall be Strafford County, New Hampshire and New Hampshire law shall apply. Judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. Each Party shall pay its own proportionate share of arbitrator fees and expenses.
BOTH PARTIES EACH IRREVOCABLY WAIVE THE RIGHT TO A JURY TRIAL IN CONNECTION WITH ANY LEGAL PROCEEDING RELATING TO THIS AGREEMENT.
IN WITNESS WHEREOF, the Parties hereto have executed this Agreement on the Effective Date.
Practice
SIGNATURE: ____________________________
PRINT NAME: __________________________
TITLE: _______________________________
DATE: _______________________________
Patient
SIGNATURE: ____________________________
PRINT NAME: __________________________
TITLE (if parent, legal guardian, or surrogate decision maker): ________________________
DATE: _______________________________
Attachment A (Fee Schedule)
Fees for Services are as follows:
Functional Medicine Initial Consultation $275
Functional Medicine Follow Up Visit $125