APPLICATION FOR NATURAL HEALTH COMMUNITY-BASED CARE SERVICE AGREEMENT-CLIA-CERTIFIED LABORATORY(FOLLOW-UP APPOINTMENT)

Brigette's Natural Healthcare Research and Laboratory Division

Brenda Nelson-Porter, ND, DM, MIT, Lab Director

CLIA-CERTIFIED WAIVED NATURAL TESTING LABORATORY

APPLICATION FOR NATURAL HEALTH COMMUNITY-BASED SCREENING CARE
~If you are currently experiencing a medical emergency, call 911~

See the source image

Supplemental Client Visit

I also understand this is a natural healthcare screening and data analytics service support
and not the traditional medical service provider who diagnoses, treats, or alleviates diseases or the effects of diseases
and/or administers conventional prescription medications [Firm's detailed Disclaimer].
This natural support follows HIPAA laws.

I understand waived analytes tests will used for this screening service based on "medically necessary" criteria
and the kit and lab fees may not be covered by insurance companies.

I understand since home-based waived test kits will be used; no eating, drinking (to include alcohol), or smoking for 1 hour (or as indicated in the manufacture policy) prior to collection.

This form is for a follow-up visit from your initial visit.

Do Not Type In This Box

Client Full Legal Name: Current Title:

Contact Information:

To maintain confidentiality, the email above is where medical information will be emailed; provide an email where others do not have access.

Last Virtual Natural Care Contract Date (from this provider):

Client ID/Source (indicated on physician/hospital record):

Age:    Weight:    Height:

Early Warning Signs (EWS)

Oxygen:         Temperature:

Last Blood Pressure:     Level of Consciousness:

Recent Blood Work From Primary MD Since Last Visit (Results):

Recent Comprehensive Metabolic Blood Prick/Swab/Urine Analysis From ND (Results/NA):

Known Environmental Allergies: Known Topical/Skin Allergies:

Medications Intake Change Since Last Visit (Dose/Frequency):

Natural Remedies/Supplement Intake Change Since Last Visit (Dose/Frequency):

For Military/Veterans: Again, we should always thank service members for their service.

Date PTSD Diagnosed by a Licensed Psychiatrist/MD:

Instructions: Type Your Explanations After Each Question. Do Not Remove the Text in the Textbox:

Did you follow the suggestions based on the last visit with this Firm that were discussed and/or approved by your primary private or VA healthcare provider suggested by this Firm? Explain.

Since our last virtual session, think about the value you place on: (a) The Results of the Recommended Test/Reports You Received: (b) How Important Are Your Goals To Yourself: (c) How Important Are Your Goals To Others:

Symptom 1 ~ Physical ~ Stated Last Virtual Session (Explain~Same, Improved, or Worsen/Describe~Location, Duration, Frequency):

Symptom 1(b) ~ For Women Only ~ Physical ~ Women Issues [state if pregnancy (trimester), do not have ovaries, etc] (Describe~Location, Duration, Frequency): Has this symptom even been reported to your Primary Care Physician: Are you pregnant or is there a possibility you may be pregnant at this time (last menstrual cycle):

Symptom 2 ~ Physical ~ Stated Last Virtual Session (Explain~Same, Improved, or Worsen/Describe~Location, Duration, Frequency):

Symptom 3 ~ Physical ~ Stated Last Virtual Session (Explain~Same, Improved, or Worsen/Describe~Location, Duration, Frequency):

Symptom 4 ~ Mental ~ Stated Last Virtual Session (Explain~Same, Improved, or Worsen/Describe~Location, Duration, Frequency):

Symptom 5 ~ Emotions ~ Stated Last Virtual Session (Explain~Same, Improved, or Worsen/Describe~Location, Duration, Frequency):

Symptom 6 ~ New ~ Describe~Location, Duration, Frequency:

Service Cost:

Insurance (complete is changed):

Date of Next Appointment
[Bring/Submit Any Medical Reports/Completed Therapeutic Assignments]

Client Electronic Signature (full name/last 4 of ssn) :

Caregiver Signature (only sign if Client is unable to sign):

After pressing "Submit" print your confirmation page twice, one to mail/email via pdf to the Firm and one to maintain for your records.
Mail to: Brigette's Natural Healthcare Research and Laboratory, 105 Wilson Circle, Newnan, GA 30263 USA
By pressing the submit button, I said name Client, agree to the terms and disclaimer indicated on the Client Application webpage (Brigette's Technology Consulting and Research Firm--Brigette's Natural Healthcare Research and Laboratory Division~hereby known as the "Firm"), understand that this natural support service does not diagnoses, treat, or alleviate diseases or the effects of diseases, and understand that waived lab kits will be used for this screening service for "medical neccessary" purposes and according to guidelines set forth by and authorized by the CDC (CLIA). I understand the kit and lab fees may not be covered by insurance companies, and that the said name Client is ultimately responsible for all payments. I also certify that all the information presented in this submission is true, and I consent to the use of the disclosure of this information submitted for natural healthcare lab and screening services provided by the Firm, and according with HIPAA laws. I understand that external laboratories have their own data privacy policies. I acknowledge that the said name Client's email address provided is secure, and that the Firm cannot and will not be held liable for any breach in the email system or of the information or misinformation transmitted using this electronic platform. I further understand the Firm cannot or will not be held legally liable for any symptoms (prior, current, future) to include symptoms that have been indicated or omitted in this transmission associated with the condition or disease of which a licensed medical physican (MD) or another licensed healthcare professional has diagnosed for the said named Client. I further understand that the said Client is given Informed Consent to hold a telephone and/or teleconference communication for this screening process. This Service Agreement and any dispute there under shall be governed by Federal healthcare laws and regulations set forth by the U.S. Governement and the State of Georgia, USA. Any litagations and dispute will be held in Newnan, GA, USA.

REIMBURSEMENT NOTICES

AETNA [Medicare (PPO)]: The standard CMS-1500 or UB-04 form will be used.

BCBS (ANTHEM; Obesity, Familial hypercholesterolemia): To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent effective July 1, 2015. Submit up to 2 pages of your medical records on your present condition.

AIM Specialty Health:

CIGNA: To submit, clients should complete the Medical Claim Form and send bill with this form if Cigna does not reimburse via other means.

UNITED HEALTHCARE: For purposes of this policy, a valid CLIA Certificate Identification number will be required for reimbursement of clinical laboratory services reported on a1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent.

GOVERNMENT: The CMS-1500 Form is used by individual professional health care or health care related providers to file for reimbursement of civilian health care services or supplies provided to TRICARE beneficiaries. This is the national standard claim form accepted by all major commercial and government payers.