Patient Name and Contact Information
(Confidential medical information cannot be sent over email. PhxMHC will respect patient confidentiality and will only send confidential medical information over the internet if a waiver has been signed)
You may request that we may communicate with someone regarding your medical information, X-ray, Prescriptions, laboratory results, scheduling appointments, etc. on your behalf. Please designate this person below by choosing Yes. We are not required to agree to this agreement, and may use medical judgement to protect patients privacy. Information will be shared with who you have indicated by choosing, Yes, when information is necessary for your treatment and care.
Please provide as much detail as possible: dates, events, medication names, dosage, began medication-
discontinued medication etc.
(Please include medication, supplements, herbs, vitamins, over-the-counter. Please be as detailed as possible.)
(Please list all known allergies including environmental, medications, foods, supplements, cleaning products, beauty products)
(Start with the most recent; include as much as you can recall. Leave blank if you’ve have had no hospitalizations or surgeries)
We are a 100% Cash fee for service practice, Cigna excluded.
We accept Cash, Credit/Debit, Health Saving Accounts, & Checks.
Office fees are associate with all office visits, prescription refills, phone consultations, disability claims, prior authorizations, patient related paperwork not associated with your visit
New Patient office visits: $219
*Required lab work and medications are not included.
Follow Up office visits: $169
*Required lab work, medications, are not included. Cost vary on patient needs.
*Medication adjustments, Lab Review, treatment plan assessment/adjustments.
*Any patient on prescription meds will require at least 3 Follow up visits a year.
Includes medication refills and adjustments. Most common visit.
Patients receiving any prescription medications must be seen in the office every 3 months (4 times a year) for Follow Up ($169) office visits and have relevant lab work at least every 6 months.
50% off your original office visit for cancellation and no shows within 24 hours
Release of Liability
Release of liability must be signed before any health care services will be provided.
Any information given in person/email/phone/text provided to patients/potential patients/customers or inquires is not medical advice for the treatment or cure of any disease, unless specified by a licensed PhxMHC medical provider during a scheduled medical visit.
It is recommended that your Primary Care Physician be notified of all of your medical conditions appropriately after you have been seen at the PhxMHC. The patient agrees to take the responsibility of informing their practitioners both primary care/allopathic and alternative/traditional/integrative of all medical treatments and updates in their health care.
PhxMHC/PhxNMDC provides health care specializing in allopathic/alternative/traditional/integrative/naturopathic treatments for Medical Weight Loss (Diabetes, Metabolic Syndrome, Obesity, Overweight), Thyroid Management, HRT
(Hormone Replacement Therapy for Men and Women, Peri-Menopause, Menopause, Andropause, Erectile Dysfunction), And Erectile Dysfunction. For any medical condition that cannot be managed by PhxMHC physicians will be referred out to the patients Primary Care Physician, ER, Urgent Care or Specialist. The patient acknowledges that they will follow through with the referral for further medical care.
I have read the above release of liability and understand that my seeking of additional health care should/can be cleared by my primary care physician. I am seeking assistance from the PhxMHC for additional/alternative/traditional/integrative medical care. If my medical needs are not meet either by any recommendation or if I feel I need additional care, I will take responsibility for contacting my Primary Care Physician for additional medical services.
I will make my Primary Care Physician aware of my past/current and future intentions for medical treatments, traditional, alternative, acupuncture, botanical medicine, homeopathy, colon hydrotherapy, sauna, detoxification, yoga, massage, myoskeletal, natuoropathic, and I will request the clearance from my primary care physician. I will inform Phoenix Men’s Health center if I would like them to become my new Primary Care Physician.
I release liability from any PhxMHC medical provider/employee/staff/volunteer or instructor for any treatments/care/advice if it has not first been discussed or approved by/with my Primary Care Physician. I understand that it is my responsibility to keep my primary care physician aware/updated on my seeking of additional health care with/and/or/for traditional, alternative, acupuncture, botanical medicine, homeopathy, colon hydrotherapy, sauna, detoxification, yoga, massage, myoskeletal, natuoropathic, and integrative medicine.
have read the above statement and agree to all information contained within.
Consent to Treat
I understand that I may be receiving acupuncture, homeopathy, botanical medicine, colon hydrotherapy, myoskeletal work, naturopathic care, Nutrient/chelation/cancer IV, and allopathic care (Integrative Medicine) for the treatment of my health condition. I understand that acupuncture treatments in the state of Arizona are not a primary health care modality. If I choose to have one or any of the above treatments, I must maintain contact with my primary care physician. I understand that seeking Walk-In, Integrative Medical, Naturopathic, Colon Hydrotherapy treatment does not replace seeing my primary care physician.
I would like the possibility to receive acupuncture, homeopathy, botanical medicine, colon hydrotherapy,
myoskeletal work, Nutrient/cancer/chelation IV, and allopathic care. I will maintain my primary care physician.
-I understand that the potential benefits of acupuncture, homeopathy, botanical medicine, colon hydrotherapy, myoskeletal work, and naturopathic care include drugless relief of my symptoms and an improved state of health. I understand that the potential risks of acupuncture include local discomfort and bruising, with a potential for infection at the site of the needle insertion.
-In addition, I understand that I may be prescribed Chinese or American herbs to take to help relieve my condition. I understand that Chinese and American herbal formulas are not regulated in the state of Arizona and that under rare circumstances people experience certain side effects from the herbs.
-With my understanding of the above, I voluntarily consent to receive acupuncture, homeopathy, botanical medicine, colon hydrotherapy, myoskeletal work, IV cancer, IV chelation, IV nutrient care, and allopathic care/treatment. I am fully aware of any potential complications and am able/healthy enough/of sound mind and body to seek further medical advice/assistance from my other health care practitioners.
All payment for services provided are due at the end of each medical visit. It is understood and accepted by the patient/client that medical services can be discontinued for late/missing/absent payments for services/supplements/medications. This includes and is not limited to patient medication refills, prescription writing, time with physician, phone calls, e-
mails, text messaging and communication. Patient will be made aware of their financial standing before services may be discontinued. The patient is seeking traditional/alternative/acupuncture/botanical medicine/homeopathy/colon hydrotherapy/sauna/detoxification/yoga/massage/myoskeletal/IV nutrient/cancer/chelation natuoropathic health care.
Payments may be collected in cash, credit, debit, or check. Trading of professional services is not available for any medical treatments.
-$219-$350 for initial visits. Primary Care/Integrative Testosterone Therapy $219 & Womens BHRT $350.
-$169 Primary care /Integrative, 30min Follow Up visits, prescription writing, prescription refills, phone calls/text messaging initiated by patient/client, plus any medication/supplementation/acupuncture/homeopathy or physical adjustments.
-We reserve the right to bill according to our desecration, case complexity, time, and case circumstances.
-Phone calls/text messaging/emails, prescription writing/prescription refills, patient services, patient out of network insurance paperwork will be charged in 15min increments, based on $189/hr.
-A minimum charge of $169 for prescription refills, prescribing, or alterations made to medications over the phone consultations or email. All Prescription Rx medication require a 3 month office visit or phone consult, $169.
-Shipping charges and sales tax will be applied to all shipped supplements and medications.
-All supplements and medications sold in office will have a city and state sales tax applied.
-Services on the phone, text, email or other forms of communication out side of office visits will be billed in 15min increments at $219 per hour, presented on patient billing as Doctor/Patient Medical Consultations. All office visits include your prescriptions, phone, lab evaluations, and documentation associated with your office visit.
-Credit Card, Debit Card transactions will have a 3% “swipe fee”, to cover transactions fees associated with card.
-Concierge Rates are available. Unlimited doctor visit, contacts, Rx’s, and 25% discount on all services and medications, including Testosterone and ED Medications.
I understand that the medical services I am seeking will be charged on an 15, 30, & 60min bases for physician & office services, this includes office time, phone consultations, case research, and emails. All other services (physical adjustments), medications, supplements, IV’s will be billed in addition to the physicians & office time and included my invoices/bills/statements. I understand that the times to be billed are at the discretion of the health clinic.
We do accept Cigna. Excluded). All statements, master billing sheets, can be submitted to your insurance company, medical savings account, for reimbursement. Your information will be kept confidential with your medical records following HIPPA rules and regulations. Please initial:
Policy and Record Release Acknowledgement Form
Record Release: By completion of this form, I hereby acknowledge and authorize the release of my records to myself at the above contact information at any requested time. This request may be denied where applicable laws compel PhxMHC to do so.
Request for Medical Records
PhxMHC follows HIPAA regulations for processing medical records release at all times. A signature form is required to process any and all request for the release of medical records. Records being forwarded to a medical facility for concurrent medical care are not assessed a fee. Personal request for copies of medical records are assessed a fee of 50 cents per page, or 25 dollars for a complete chart and are sent by regular mail to the last known home address on records, or requested provider/insurance agency.
An Electronic Medical Record of healthcare services will be created and maintained by PhxMHC. Applicable state and federal laws protect the confidentiality of your medical records and information as well as grant you the right to see or obtain a copy of records we will have on file electronically or hardcopy. Your medical information will not be disclosed to others unless we are directed to do so in writing or applicable laws authorize or compel us to do so. PhxMHC is required to provide you, at your request, with a copy of its Notice of Privacy Practices and to obtain a written acknowledgment that you have reviewed it. The notice outlines the types of uses and disclosures that may occur involving your protected health information, explaining your rights and you may exercise those rights. If you have any questions concerning the management of your healthcare information at our clinic, or wish to inquire about your rights, please contact PhxMHC at 602-908-5422.
Role of PhxMHC in your Health Care
Physician are licensed naturopathic medical doctors in the state of Arizona. Patients are encouraged to inform the physician if they would like the doctors to act as their PCP or other practitioner in their health care. If patient does not specify with the practitioner, PhxMHC will not be functioning as your primary care physician.
Any health concerns that cannot be accommodated for at PhxMHC will be referred to ER, Urgent Care, or the patient's Primary Care Physician.
We are a cash based fee for service medical center. We reserve the right to discontinue medical services at any time and our patients have the right to discontinue medical services at any time.
Communication with Office:
Messages left for the doctor will be returned in the order they are received or my medical necessity. If you do not receive a phone call within 24hrs please call back and leave another message. Any phone call to the doctor regarding new conditions or existing conditions may result in a consultation fee based on time discussing condition.
All communication must be, voice mail, phone call, email (email@example.com), or online scheduling software (GenBook). Text messages are not an acceptable form of communication for medical information and will not receive any responses from our office.
During normal business hours please call: Phoenix Men’s Health Center (602) 908-5422
In the event of an emergency, dial 911
• All scheduled appointments require 24hr prior notice of cancellation
• Cancelations within 24hrs assess a late cancelation fee of 50% of scheduled office visit.
• Patients who miss two consecutive appointments without calling to reschedule, or any attempts to
reschedule may/will be/are releasing themselves from medical care.
All sales are final for supplemental products, botanical medications, multi-vitamins, minerals, and homeopathic remedies.
To our patients: This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Our commitment to your privacy
Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information.
We realize that these laws are complicated, but we must provide you with the following important information:
Use and disclosure of your health information in certain special circumstances
The following circumstances may require us to use or disclose your health information:
1. To public health authorities and health oversight agencies that are authorized by law to collect information.
2. Lawsuits and similar proceedings in response to a court or administrative order.
3. If required to do so by a law enforcement official.
4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.
5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
6. To federal officials for intelligence and national security activities authorized by law.
7. To correctional institutions or law enforcement officials, if you are an inmate or under the custody of a law enforcement official.
8. For Workers Compensation and similar programs.
Your rights regarding your health information
1. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.
2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations.
Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Phoenix Men’s Health Center-2601 N. 3rd St., Suite 304, Phx, AZ 85004.
Note: We must respond to this request within 30 days.
4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Phoenix Men’s Health Center-2601 N. 3rd St, Suite 304, Phx, AZ 85004. You must provide us with a reason that supports your request for amendment.
Note: We must respond within 60 days. The Privacy Officer or the patient’s physician will usually do this. If the physician believes the information is complete and accurate, the physician can refuse to make any changes.
5. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact the front desk receptionist.
6. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact the Office Manager of Phoenix Natural Medicine and Detox Center or Dr. Le Provost with Phoenix Men’s Health Center. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
7. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.
If you have any questions regarding this notice or our health information privacy policies, please contact the
Office Manager at Phoenix Men’s Health Center.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have received a copy of the Phoenix Men’s Health Center Notice of Privacy Policies.
Testosterone Therapy Information and Consent
If you are interested in testosterone therapy, please fill out this page. If not, please skip and submit the form.
Testosterone Therapy can be administered in many forms; creams, pellets, injections, sub-lingual, and patches. Bio-identical testosterone is a compounded hormone, biologically identical to the testosterone naturally biologically made in your own body. The goal of testosterone hormone replacement is to have the same effects on your body as your naturally testosterone, The pellets and creams that we use for Bio-identical hormone therapy are made from yams, and come from compounding pharmacies. Risk of bio-identical hormones are considered by some to be similar to those of any testosterone replacement but may be lower due to the bio-identical form that the body is more familiar with and recognizes as its own.
Risks of not receiving testosterone therapy after andropause include but are not limited to:
Diabetes, elevation of cholesterol, obesity, loss of strength and stamina, osteoporosis, melancholy mood disorders, depression, erectile dysfunction, loss of skin tone,increased overall inflammatory processes, arthritis, loss of libido, dementia, and insomnia.
CONSENT FOR TREATMENT: I consent to testosterone treatment either with creams, injections, sub-
dermal pellets, or sublingual oral. If I choose to perform sub-dermal pellet procedure, I have been informed that I may experience the complications to this procedure. See below. Surgical risks are the same as for any minor medical procedure.
Side effects may include:
Bleeding, bruising, swelling, infection and pain. Lack of effect (typically from lack of absorption). Thinning hair, and male pattern baldness. Increased growth of prostate and prostate tumors. Extrusion of pellets. Hyper sexuality (overactive libido). Up to 25% percent size reduction in testicle and reduction in sperm production.
Some risk with natural testosterone therapy may include; enhancing an existing current prostate cancer to grow more rapidly, increase one’s hemoglobin and hematocrit. All of which will be monitor via blood work quarterly, or yearly.
PSA prostate specific antigen blood test is done before starting testosterone (pellet injection, cream, or sublingual ) therapy and will be conducted each year thereafter. If there is any question about possible prostate cancer, a follow-up with an ultrasound of the prostate gland may be required as well as a referral to a qualified specialist. While urinary symptoms typically improve with testosterone, rarely they may worsen, or worsen before improving.
Increased libido, energy, sense of well-being, muscle mass, strength and stamina. Reduction of migraine headaches. Stability of mood, anxiety and irritability (secondary to hormonal decline). Decreased weight (Increase in lean body mass). Reduce risk or severity of diabetes, better blood sugar control. Decreased Dementia risk. Decreased risk of heart disease in men less than 75 years old with no pre-existing history of heart disease.
On January 31, 2014, the FDA issued a Drug Safety Communication indicating that the FDA is investigating risk of heart attack and death in some men taking FDA approved testosterone products. The risks were found in men over the age of 65 years old with pre- existing heart disease and men over the age of 75 years old with or without pre-existing heart disease. These studies were performed with testosterone patches, synthetic testosterone creams and synthetic testosterone injections and did not include bio-identical creams and subcutaneous/sub-dermal hormone pellet therapy.
PhxMHC considers creams and pellets of bio-identical testosterone to be the safest form of testosterone therapy.
The physician discussed with me in detail the pros and cons of TT (Testosterone) Tx. Explained the pathways of hormones, feedback mechanisms, short and long term effects, potential SE (decreased fertility & decreased testicular size). Different tx options for TT tx from natural, to prescription, cost of each, and all additional testing and follow up that would be required. I understand and would like to move forward with TT Tx.
Also discussed the recent changes with the FDA regarding TT tx. We told the pt:
Although the following is not demonstrated in the vast majority of studies, the FDA has recently put a block box warning on testosterone prescriptions. This warning states that testosterone might be associated with and increased risk of MI and blood clots. However the benefits still dramatically outweigh any potential risk. I have advised the pt of these risk and they have accepted these potential side effects, they are aware of the many benefits.
I agree to immediately report to my practitioner’s office any adverse reactions or problems that may be related to my therapy. Potential complications have been explained to me and I have received information regarding those risks, potential complications and benefits, and the nature of bio-identical injections/creams/pellets and other treatments and have had all my questions answered. Furthermore, I have not been promised or guaranteed any specific benefits from the administration of testosterone therapy. I certify this form has been fully explained to me, and I have read it or have had it read to me and I understand its contents. I accept these risks and benefits and I consent to the insertion of hormone pellets under my skin, or injection or trans-dermal cream therapy. This consent is ongoing for this and all future insertions, injections, or cream applications.
I voluntarily choose to being/undergo testosterone therapy either of subcutaneous bio-identical testosterone pellet therapy, cream, or injections with Phoenix Men’s Health Center even though I do have or do not have (choose one below) a history of prostate cancer. I understand that such therapy is controversial and that many doctors believe that testosterone replacement in prostate abnormality cases is contraindicated. My Treating Provider has informed me it is possible that taking testosterone could possibly stimulate existing prostate cancer (including one that has not yet been detected). Accordingly, I am aware that prostate cancer or other cancer could develop while on pellet therapy.
I have assessed this risk on a personal basis, and my perceived value of the hormone therapy outweighs the risk in my mind. I am, therefore, choosing to undergo the injection, cream, or pellet therapy despite the potential risk that I was informed of by my Treating Provider.
I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or prostate issues) that may be sustained by me in connection with my decision to undergo testosterone therapy including, without limitation, any cancer that should develop in the future, whether it be deemed a stimulation of a current cancer or a new cancer. I hereby release and agree to hold harmless Dr. Le Provost, Phoenix Men’s Health Center and any of their medical physicians, nurses, officers, directors, employees and agents from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of testosterone injection, cream or pellet therapy. I acknowledge and agree that I have been given adequate
opportunity to review this document and to ask questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives. I understand that a prostate exam is important and part of the screening processes. At this time, I am choosing to:
PhxMHC must have a recent/updated (within in 3 months) PSA report in patients medical records prior to any BHRT, Testosterone Replacement therapy.
Prostate exam is a method for detection of early prostate cancer. I understand that my refusal to submit to a prostate exam may result in cancer remaining undetected within my body. Hormone therapy may increase the risk of increase of such undetected cancer.
I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or prostate issues) that may be sustained by me in connection with my decision to undergo testosterone injection, cream or pellet therapy including, without limitation, any cancer that should develop in the future, whether it be deemed a stimulation of a current cancer or a new cancer. I hereby release and agree to hold harmless Phoenix Men’s Health Center, Dr. LeProvost or treating provider under Phoenix Men’s Health Center, including, nurses, officers, directors, employees and agents from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of testosterone replacement therapy via injections creams or pellet therapy. I acknowledge and agree that I have been given adequate opportunity to review this document and to ask questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives.
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