acadiananaturalhealth.comacadiananaturalhealth.com/.../2017/...NEW-8152017.docx · Web viewModalities used include nutrition, nutraceuticals, homeopathy ... printed, electronic,

Client Membership Guide Because You Deserve a Better Healthcare Experience

Our MissionAcadiana Center For Natural Health, LLC (ACNH) is dedicated to enabling our community to be as healthy as possible and welcomes clients at any stage of life. Our goal is to provide you and your family high quality, effective Naturopathic Healthcare at affordable rates. We’ve created a Naturopathic direct care membership model that empowers you to take control of your health. Our model is client centered, low force, low cost, efficacious, preventative in nature, and affords ample time to spend with each client in order for a deep healing relationship to be formed.

About Acadiana Center For Natural Health (ACNH) Acadiana Center For Natural Health is a Naturopathic Direct Care Practice. As such, this practice is not insurance. ACNH may not bill insurance or the Medicare/Medicaid programs. Furthermore, ACNH’s Members are not allowed to submit claims to their insurer for any service(s) included in the membership. Our practice provides only the limited scope of direct care services specified in our medical agreement. Clients must pay for all services not specified in the medical agreement. ACNH or the client shall have the right to terminate this agreement at any time, provided that ACNH or the Client provides the other with 30 days prior written notice of such termination.

Acadiana Center for Natural Health Client Membership GuideBecause You Deserve a Better Healthcare Experience

325 Kaliste Saloom Rd. Suite 101, Lafayette, LA 70508

Office: 337-210-5827 (Fax): 844-482-4077Admin Email: [email protected]

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mailto:[email protected]

Clinic InformationACNH’s Naturopathic Clinic (Lafayette)

Address

325 Kaliste Saloom Rd. Suite 101 Lafayette, LA 70508

Phone (337) 210-5827Fax (844) 482-4077

HIPAA Compliant Email: [email protected]

Clinic HoursMon, Tues, Wed. 9 am-3pm

Thursday 9 am-6 pm,Fridays 9:00 am-1:00 pm




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https://www.google.com/maps/place/Acadiana+Center+for+Natural+Health/@30.1836801,-92.0172432,16.94z/data=!4m13!1m7!3m6!1s0x86249d1b819756dd:0xb533078cc2708b90!2s325+Kaliste+Saloom+Rd+#101,+Lafayette,+LA+70508!3b1!8m2!3d30.183643!4d-92.014962!3m4

ACNH Client Membership Guide

ACNH’s Client Guide describes the services and amenities provided by the physician at ACNH to those who are enrolled in one of our Membership Plans (“MP”). Please note this guide includes our Naturopathic Direct Care Agreement. This guide, also, outlines the different levels through which you may benefit and participate in a MP, the services offered in each MP, the cost of extra services, and fully articulates the terms and conditions of your membership.

If you have any questions at all, please feel free to connect with us at: (337) 210-5827 or email: [email protected]

Our Philosophy of Naturopathic Medicine Our Naturopathic Physician practices medicine with the philosophy that the human body, when given the right conditions, can maintain and restore health. We work with our clients to put in place sustainable health strategies that promote vitality through the use of natural, low force interventions, along with the judicious use of higher force interventions when applicable.

Naturopathic Medicine employs natural therapeutics and a holistic approach to treatment(s). Modalities used include nutrition, nutraceuticals, homeopathy, biotherapeutic drainage, and botanical medicine. Naturopathic medicine can be used for arthritis, diabetes, hormonal imbalances, cardiovascular disease and many other common conditions.

The Principals of Naturopathic Medicine

The Healing Power of Nature (Vis Medicatrix Naturae)

Naturopathic medicine recognizes the body's inherent ability to heal itself. Naturopathic physicians identify and remove obstacles to recovery and facilitate this healing ability in Clients.

Identify and Treat the Causes (Tolle Causam)The naturopathic physician seeks to identify and remove the underlying causes of illness, rather than eliminate or merely suppress symptoms.




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First Do No Harm (Primum Non Nocere)Naturopathic medicine follows three principles to avoid harming the Client:

Use methods and medicinal substances which minimize the risk of harmful side effects

Avoid, when possible, the harmful suppression of symptoms

Acknowledge and respect the individual's healing process, using the least force necessary to diagnose and treat illness

Doctor as Teacher (Docere)Naturopathic physicians educate the Client and encourage self-responsibility for health. They also acknowledge the therapeutic value inherent in the doctor-client relationship.

Treat the Whole Person

Naturopathic physicians treat each individual by taking into account physical, mental, emotional, genetic, environmental and social factors. Since total health also includes spiritual health, naturopathic physicians encourage individuals to pursue their personal spiritual path.

Prevention

Naturopathic physicians emphasize disease prevention, assessment of risk factors and hereditary susceptibility to disease and making appropriate interventions to prevent illness. Naturopathic medicine strives to create a healthy world in which humanity may thrive.

Wellness

Wellness follows the establishment and maintenance of optimum health and balance. Wellness is a state of being healthy, characterized by positive emotion, thought and action. Wellness is inherent in everyone, regardless of disease(s). If wellness is recognized and experienced by an individual, it will more quickly heal a given disease than direct treatment of the disease alone.




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Our Naturopathic Physician ACNH’s Naturopathic Physician maintains her naturopathic medical license in Washington State. She is trained as specialists in natural medicine.

Our naturopathic physician received her training and doctoral degree at Bastyr University in Kenmore, Washington, a four-year accredited medical school program and participates in continuing education to maintain her naturopathic medical license.

In addition to the standard medical curriculum, naturopathic physicians must do extensive coursework and clinical study in natural therapeutics.

For more information about Naturopathic Medicine please visit the following sites. http://www.cnme.org/https://www.nabne.org/http://www.naturopathic.org




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http://www.naturopathic.org/

https://www.nabne.org/

http://www.cnme.org/


Contacting our Naturopathic Physician Membership includes access to your physician on your terms. Our physician is available in person, via phone, email, & Skype.




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“I practice in Lafayette, La at Acadiana Center for Natural Health. Where I strive to make my clients and community feel welcome. I work with people of all ages that may be dealing with acute or chronic illness that is negatively impacting their health. I look at indications of your state of health and use them as a guide to address the cause of your health issues. I am committed to identifying the root cause of your health issues and will work with you until we do. I am passionate about the career I have chosen and I will work to motivate, inspire, and empower you to make health an attainable goal.

Membership Plans Our MPs provide you the one-on-one time with ACNH naturopathic physician and ongoing continuous care, but this is not an insurance practice and our plans do not function as an insurance policy and do not replace insurance.




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Disclosure of Service Inclusion/Exclusion

As part of her service, Dr. Duhon will review indications of your state of health and use them as a guide to address the cause of your health issues. Further, Dr. Duhon may make




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recommendations on lifestyle modifications, diet, dietary supplements, or suggest naturopathic remedies to assist you in solving your health issues.

Dr. Joy Duhon is not licensed, certified, or registered as a “health care provider” in the state of Louisiana. Further, any any food or dietary supplements being recommended are not medically prescribed drugs.

I understand this disclaimer in its entirety, been allowed to ask any questions I might have about it, and sign it of my own free will.

__________________________________Patient Name

__________________________________ ______________Patient Signature Date

If a service is not specified below, there is an additional fee associated with the service. All fees incurred by the client(s) are the client(s)’s sole responsibility. This includes equipment, materials, additional labs, imaging, specialist referral, etc.

Direct Care Services Included in ALL our Membership Plans:

Wellness care, which includes coaching/counseling for lifestyle things like diet, exercise, stress management, behavioral modification, etc.

Women's care

General pediatric/adolescent care, including chronic condition management

Chronic illness management for anybody system, ie. Nervous, cardiovascular, endocrine, digestive etc. ; this includes consultation, referral, and coordination of care to specialists in the appropriate field

Same-week appointments if scheduled by the first day of the week (Monday)

Yearly labs that will include CBC, CMP, Lipid panels. All other labs that may be recommended are not part of the MP and the client will be responsible for lab fees.




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Supplement management

15% off all supplements in office and 10% off all supplements from online dispensary.

Consultation referral, and coordination of care to appropriate specialty providers

Recommendation of appropriate diagnostic studies

Recommending of appropriate conventional laboratory testing (blood, stool, urine, breathe, etc.) and functional lab testing

Comprehensive Care is included with all our Memberships

Services NOT Included in our Membership Plans: Any service that is not within the scope of naturopathic medicine in the state of




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Louisiana as defined in LA Act.

Dental care

Emergency room care

Obstetrics and gynecology care

Hospital care

Emergency psychiatric

Attending physician at hospital

Cost of filling prescriptions

Cosmetic surgeryDrug and alcohol dependency treatment

Hearing care

Outpatient surgery center care

Psychiatric care

Sterilization

Vision care

Physicals

Outpatient diagnostic procedures such as colonoscopy, endoscopy, radiology, ultrasound, CT scan, MRI, PET scan, advanced cardiac diagnostic tests, and mammograms.

Facility fees, such as Hospital, Nursing Home, Hospice Residential Care, Home Health and any other Facility fees.

Hospital Care Privileges The State of Louisiana does not allow for Naturopathic Physicians to have hospital




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care privileges.

Member Rights and Responsibilities We believe that if you understand your rights and responsibilities, you are better able to participate in your health care. These rights and responsibilities also apply to your designated representative, guardian, or next of kin if you are unable to advocate on your own behalf, or to a parent or legal guardian, if you are a minor.

Member Rights A Member and/or his/her legal representative has the rights to:

Receive compassionate, competent, respectful treatment and care.Access to care regardless of race, color, religion, gender, ethnic origin, age,

disability, source of payment, or any other classification prohibited by law.Be interviewed in surroundings that permit reasonable visual and auditory

privacy. Have another person present during appointmentsReceive complete health recommendations & current information concerning

assessment, natural health treatment, and prognosis in terms reasonably understood.Participate in decisions about your care, including consent, withdrawal of

consent, and preparation of advance directives.Refuse recommendations and accept the potential consequences of that choice

after thorough explanation Expect reasonable continuity of careKnow the identity and professional status of health care providers.Receive informed consent regarding procedures, risks and alternatives, and

receive answers to questions Bring complaints or grievances to the attention of staff without jeopardizing

access to current or future care or services.Disclosure of unanticipated outcomes.Access, copy, and amend records.Know that your records will remain confidential and will be released only with

your written permission.Request certain restrictions on how your information is used.

Member Responsibilities A Member and/or his/her legal representative has the responsibility to:




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Be honest and forthright with the Naturopathic doctor and office staff and to provide accurate and complete information about present complaints, past illnesses, accidents, hospitalizations, medications and any other information related to his/her health

Report to the Naturopathic doctor in a timely manner any new incident, trauma or changes in his/her health condition

Acknowledge and consider instructions provided by the doctor and/or office staff

Request clarification about any aspect of his/her care not fully comprehended

Keep scheduled appointments or give adequate notice of delay or cancellation.

Show respect and consideration for health care personnel, property, and other clients.

Be an active participant in making informed health care decisions.Accept the consequences when you do not comply with plan of care or

treatment.Follow the terms and conditions of this Membership Agreement.Meet financial commitments to pay all expenses associated with services

received. If you have a concern at any time during or after you receive services, we ask that you communicate with us. Our staff will do everything it can to respond and resolve the issue in a timely manner.

Notice of Privacy Practices THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS DOCUMENT CAREFULLY.

This Notice of Privacy Practices describe how Acadiana Center For Natural Health services, memberships, and independent members of the medical community, including our employees, may use and disclose your health information to carry out natural health services, payment, or health care operations and for other purposes that are permitted or required by law.




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Acadiana Center For Natural Health is committed to maintaining the privacy of your protected health information. We understand information about your health is personal and private.

Your health information, in our possession may include information created or received by this organization, and may be in written, printed, electronic, or spoken word format. This information may include your medical history, current health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, other health- related services, or billing activity records.

We maintain the privacy of your protected health information. This document details the ways in which Acadiana Center For Natural Health may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of this information.

We may use and disclose your information for the following purposes without requesting or obtaining your consent or authorization:

Treatment We may use and disclose your health information as necessary within Acadiana Center For Natural Health and with other outside health care providers to provide you with Naturopathic treatment or services. For example, health care professionals treating you will document information about services you receive. This record will be released to other health professionals assisting in your treatment to ensure that they are fully informed about your medical condition and treatment needs.

Payment

We may use and disclose your health information so the treatment and services you receive from our organization may be billed to and payment collected from you.

Healthcare Operations

We may use and disclose your health information for purposes of maintaining and improving the quality and performance of Acadiana Center For Natural Health or that of another health care provider or health plan you have a relationship with.




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Appointment Reminders

We may contact you as a reminder that you have an appointment for treatment or medical care at our clinic.

Other Uses and Disclosure of Health Information

All other uses and disclosures of health information not covered by this notice or the laws that apply will be made only with your written authorization. If you provide us authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reason covered by your written authorization.

Right to Inspect and Copy

You have the right to inspect and copy health or billing information that may be used to make decisions about your care. If you request a copy of the information, we may charge a copying and mailing fee that covers the costs associated with this request.

Right to Amend

You have the right to request an amendment if you believe health information we have about you is incorrect or incomplete. The request must be made in writing to and must include a reason for the amendment. We may deny your request if:

The request is not in writing or does not include a reason to support the request.

The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment.

The information is accurate and complete. Right to Request Restriction You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for services you receive, such as a family member or friend. To request restrictions, you must submit




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a written request to us.

Right to Request Confidential Commutations

You have the right to request that we communicate with you about health matters in a certain way or at a certain time and place. Your request should be submitted in writing and must specify how or where you wish to be contacted. We will accommodate all reasonable requests. We will not ask you the reason for your request.

Right to a Paper Copy of this Notice

You have the right to a paper copy of this notice at any time.

Changes to this Notice

We reserve the right to change this notice at any time and to make the revised notice effective for health and billing information we already have about you, as well as any information we receive in the future. The current notice will be posted at ACNH’s Clinic and will be made available to you at your request. The effective date of the notice will be on the first page in the top right-hand corner.

Payment Terms and Termination Policy To become a member of a MP offered by Acadiana Center For Natural Health, complete and return the attached authorization forms together with your check or payment instructions. For new members the period of your participation in your chosen MP is one year; beginning on the date you sign the member agreement. For established members participating in the program, renewal of your contract will be continuous. There will be no break in the contract period. Payments are still made in the manner agreed upon the prior year. Payment Election may be annually, bi-annually, quarterly, or monthly.

Late Payments and Returned Items In the spirit of simplicity and peace of mind we ask that our members pay electronically by automatic bank withdrawal, credit card, debit card. This not only




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simplifies the payment process, it also allows you to avoid any late payments and keeps our relationship with you about your health. Late payments will result in a 10% charge on any balance in a 30-day period.

Payments are processed by Hint Health at Hint.com, HIPAA-Compliant. We add a $25.00 Service Charge to all returned items.

Early Termination, Refunds, and Reenrollment Fees

The term of Agreement shall be for one (1) year increments starting on the effective agreement date, continuing until notification is given to terminate by either party. Either ACNH or the Client shall have the right to terminate this agreement at any time, provided that ACNH or the Client provides the other with 30 days prior written notice of such termination. If the situation arises that a member does or may not provide 30 days notice of termination, ACNH will keep the portion of fees paid necessary to cover services or products already rendered. If the member cancels within the first 30 days of joining, the member shall owe the fee for one regular visit.

Fee and Benefit Changes We are always planning ahead to ensure you have a great experience with us and sometimes we may foresee changes in costs due to changes in regulations, products, and taxes. Thus, in order to continue to be able to provide excellence through care, we may at times have to increase fees as a result. As our valued member, you will receive notification 30 days prior to any price changes. If benefits or prices change during the duration of your current MP year, the new changes will not affect you until the next 1-year MP cycle begins. This agreement is on a continual renewal basis, and the price increase, if any, will be applied to your next year renewal. You must cancel to avoid paying for subsequent undesired renewal.

Definitions Wellness panel is defined as Complete Blood Count w/auto-differential of white blood cells, Comprehensive Metabolic Panel, and Lipid Panel. These labs are included in the cost of membership at no extra cost. Any additional required labs will be the client’s responsibility.




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Direct Naturopathic Care Agreement is defined as a contract between ACNH and an individual client or his or her legal representative and/or family in which ACNH agree to provide direct naturopathic care services to the individual client(s) at the agreed upon level of membership.

Discount on Herbs, and Nutraceuticals is defined as the corresponding discount available off of the retail price of a product(s) in our Dispensary. To all clients in enrolled in ACNHs MP will receive 15% off products in office and a 10% discount in our online dispensary.

Appointment is defined as a scheduled appointment with an ACNH naturopathic physician. Length of time does not matter in regards to what constitutes a visit. 15 minutes and an hour are both considered a visit. Length and the amount of necessary visits are at the doctor’s discretion based on their personal medical judgment and management approach. In the event of your usual naturopathic physician being absent, another ACNH physician will be present to schedule a visit. If your naturopathic physician is out of town appointments can be scheduled as phone appointments or Skype appointments.

House Call is defined as a mobile visit to your home by one of ACNH’s naturopathic physicians. House Calls are available up to a 15-mile radius from our clinic. Your usual provider will make all possible attempts to be the one making the house call. However, if circumstances dictate, another provider may be the one who makes the call. Each member can receive one house call a year within the 15-mile radius of ACNH. House calls can only be made after ACNH regular business hours.

Member is defined as a person(s) who voluntarily elects ACNH and their naturopathic physicians to provide direct naturopathic care, as set forth in the terms of this agreement.

Naturopathic Physician means a person who holds a degree of Doctor in Naturopathic medicine from an accredited naturopathic medical school.

ACNH’s Dispensary Products include vitamins, minerals, medicinal herbs, food supplements, fish oil, probiotics, hair / skin / tooth care products, healing salves and oils (for topical use), homeopathics, and medical grade foods. The goal of it is to support body systems that need healing, provide cleaner, healthier solutions to




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products used on a daily basis, and to support a healthy diet and lifestyle.

Wholesale Lab Testing is defined as sharing the discounted physician laboratory rate directly with all ACNH members. We are passing this discount on to you, which means, we aren’t marking up the labs to make money off of you. Rather, we are helping you to better afford necessary labs.

Access to Your Naturopathic Physician Through Your Client Portal is defined as access to your chosen naturopathic physician’(s) via email through your client portal. When leaving email messages, your provider will respond to you within 24 hours, except in rare situations where your physician may have limited access to internet/email. You will be informed in advance if this is the case. Email consultation is not acceptable means of communication for an emergency. If you have a life- threatening emergency, go to the emergency room or call 911 immediately.

Direct Naturopathic Care Agreement This Agreement specifies the terms and conditions under which you, your spouse, and/or dependents included in the Agreement will participate in the Membership(s) available under this Agreement. Adult Members participating in the Agreement may sign up a spouse and/or dependents under this Agreement. Others outside of that relationship wishing to join as Members must have their own separate Agreement. If the Member is younger than 18 years of age, this Agreement is being entered into on the behalf of the Member by their Parent or Legal Guardian. A valid picture ID is required to enroll in a membership and will be required to verify identity before receiving membership services, except in the case of a minor enrolled in the membership, who must be accompanied by a Parent or Legal Guardian.

Direct Naturopathic Care Agreement

This Direct Naturopathic Care Agreement (the “Agreement”) is entered and effective on:, 20 by and between Acadiana Center For Natural Health, (“ACNH”), a Louisiana

LLC, located at 325 Kaliste Saloom Rd. Suite 101 Lafayette, LA 70508

and you (the “Member”)below (include a separate sheet if




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necessary) and includes the following person(s) listed

Name

Date of Birth

Relationship

Scope of Service: The Member(s) acknowledges and understands the following: 1. This Agreement is a legal document and creates certain rights and

responsibilities for both parties. ______(initials)

2. This Agreement is NOT A HEALTH INSURANCE POLICY and THIS PRACTICE IS NOT INSURANCE. ______ (initials)

3. The membership fees required under this Agreement DO NOT apply towards any health insurance plan deductible. ______ (initials)

4. The membership under this Agreement DOES NOT by itself fulfill the personal health insurance mandate under the Affordable Care Act (commonly known as “Obamacare”). ______ (initials)

5. Neither ACNH nor their naturopathic physicians will seek any reimbursement from any insurer, Medicare, Medicaid, or any third party payer for any services included in this Agreement. ______ (initials)




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6. If ACNH’s clinic or provider(s) renders services beyond the scope of this Agreement, there will be added charges that are the sole financial responsibility of the Member. The Member(s) agree to pay for these additional charges at the time of service. If these or any other additional charges are not paid at the time of service, Member(s) agree to allow ACNH to charge the Member(s) account on file for those amounts. ______ (initials)

7. All fees incurred by the Member(s) that are not listed as covered by this Agreement are the Client’s sole responsibility. This includes equipment, additional labs, imaging, specialist referral, etc. ______ (initials)

8. This Agreement DOES NOT include any major catastrophic medical care provided by emergency rooms, hospitals, urgent care centers, services rendered by specialists or specialty clinics, laboratory testing or other entities not outlined specifically. ______(initials)

9. The member acknowledges sole financial responsibility for any services not offered by ACNH or this Agreement. Because of this, the Member(s) is advised to consider a high- deductible insurance plan, as a supplement to this agreement. ______ (initials)

10. ACNH makes no representation regarding the tax implications of membership of this agreement. Members are encouraged to seek the advice of a competent tax professional for advice regarding any related tax issues. ______ (initials) 29 Acadiana Center For Natural Health Client Membership Guide Because You Deserve a Better Healthcare Experience

11. The Member(s) understands they have the right (at all times) to a fair, fast and objective review of any complaint against their health care clinician(s) or any other staff, including complaints about wait times, operating hours, conduct of personnel, business practices and adequacy of health care services and facilities. Please see our Notice of Complaint and Grievance Policy/Process on page 19 for more information ______ (initials)

Terms and Conditions:




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12. The term of this Agreement is for one (1) year, beginning on ,20 . After the initial year commitment, renewal of this contract will be continuous and automatic. There will be no break in the contract period. Payments will continue to be made on the agreed schedule set forth below.

13. By voluntarily entering into this Agreement and remitting the retainer medical fees, set forth below, the Member(s) gains the membership level of their choice: Base Camp, Summit, and/or Kid’s Camp.

14. The services included in this agreement are personally administered by ACNH’s naturopathic physician who maintains her naturopathic medical Licensed in Washington State, She does not hold a medical license in Louisiana State: Dr. Joy Duhon, ND

15. This Agreement only covers the services specifically outlined in the Disclosure of Service Inclusion, Exclusion (page 8 of ACNH Member Guide). Please see Disclosure of Service Inclusion/Exclusion for the full list of covered and excluded benefits and services associated with this Agreement.

16. This Agreement is bound to the Member Rights and Responsibility (pages 11-12 of ACNH’s Member Guide).

17. This Agreement is bound to the Privacy Policy (page 12-15 of ACNH’s Member Guide).

18. This Agreement is bound by the Payment Terms and Termination Policy (pages 15-16 of ACNH Member Guide).

19. This Agreement is bound by the definitions set forth in Definitions (pages 17-18 of the ACNH’s Member Guide).

Fees: At the date of this agreement the prices of the ACNH membership are

Single Payer Plan: Monthly $109.99 or $1319.88 annuallyFamily Plan: Monthly 189.99 or $2279.88 annually.




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Membership plans can be automatically debited monthly on the same recurring day or debited annually.

This agreement and the associated authorization forms are the parties’ entire agreement on this matter, superseding all previous negotiations, estimates, or agreements. This Agreement can only be changed by mutual written consent. This Agreement shall be governed by, and construed in accordance with, Louisiana State law.

Signatories:

By signing below, I admit full comprehension of all information contained in the above pages, including but not limited to the benefits and services included in my chosen plan(s), as well as their definitions; the payment, terms, and termination policies; the disclosure that this is not an insurance policy; my responsibility and authorization for payment for myself and any additional members listed as covered herein.

I acknowledge that either ACNH or I can terminate this agreement upon 30 days written notice. If I terminate the agreement early, ACNH retains the right to collect the difference of services rendered in order to cover expenses. This is defined as non-member prices for the member services rendered, minus the amount currently paid toward the current MP year. If ACNH terminates, I will receive a refund of the prorated portion of the paid fees, based on the number of days elapsed in the service of the current year and the services received. Such refund will be paid to me within 45 days of termination.

I may renew this agreement at any time for subsequent MP years by paying the annual fee for the applicable MP year as determined by ACNH. The terms of this Agreement will apply to all such subsequent MP years, unless ACNH and I agree otherwise, in writing. The current MP year begins on the date this agreement is signed.

Signature:




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Date:

Printed Name: Status: Client ☐ Parent ☐ Legal Guardian☐

Authorization for Payment Beginning on:_____________(mm/dd/yyyy) and ending on:______________(mm/dd/yyyy)

I/WE have engaged Acadiana Center For Natural Health to provide Naturopathic medical services to me/us for a period of one year and I/We elect the following membership(s):

[ ] Single Payer Plan

Circle One: (x1, x2, x3, x4) members I/We will pay:[ ] 1319.88 annually [ ] $109.99 monthly

[ ] Family Plan

Circle One: (x1, x2, x3, x4) members I/We will pay:[ ] $2279.88 annually [ ] $189.99 monthly

I/We choose the following payment schedule:

Total

The Payments are scheduled for the 1st or 15th of every month. In the amount of________ to be paid

[ ] Annually [ ] Monthly

_______Number of installments at the rate of________per installment.

Method Of Payment:

[ ]Cash[ ] Debit Card[ ] Automatic Withdrawal from Bank Account[ ] Credit Card




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(MC, VISA, AMEX, DISCOVERY) Circle One [ ] Debit Card

Automatic Withdrawal Authorization (Bank Account) Member’s NameStreet AddressCity, State & Zip:Phone Email

Effective, ___________________(Date) I, __________________________________________, authorize Acadiana Center For Natural Health (ACNH) to make automatic withdrawals from the account shown on the attached voided check in the amount of ACNH’s membership fees. The fee payment will be drawn on the 1st or 15th day of each month. This authority will remain in effect until ACNH has received written notification from the Account Holder.

I may cancel my automatic payment or provide new/updated banking at any time by notifying ACNH in writing by 1st of the month prior to my next scheduled withdrawal.

If I miss the 1st deadline, to stop a payment on my next scheduled withdrawal, I must notify my bank no less than (3) business days before the scheduled withdrawal. I am responsible for any fees assessed by my bank for the stopping payment request.

In the event that my financial institution denies electronic payment, a non-refundable service charge of $25.00 will be assessed per occurrence.

If, at any time my account falls behind in the amount owed to ACNH, I understand ACNH reserves the right to withdraw any amount necessary to bring my account current with the next regularly scheduled automatic payment. ACNH will not withdraw any amount above that which is due at the time of withdrawal; notice may not be provided to me prior to said withdrawal.

Financial Institution:

Routing Number: check) (9 digits preceding your account number on the bottom of your check)




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Bank Saving Account Number: Bank Checking Account Number:

Bank Account Holder’s Signature Date / /

Recurring Debit/Credit Card Authorization I hereby authorize Acadiana Center For Natural Health to charge my credit card for the fees as indicated above. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Acadiana Center For Natural Health in writing of any changes in my account information at least 15 days prior to the next billing date.

The Payments will be charged on the 1st or 15th of every month. If the payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. If the debit/credit card is ever declined, a $25.00 service charge will be assessed per occurrence.

If, at any time my account falls behind in the amount owed to ACNH, I understand ACNH reserves the right to debit any amount necessary to bring my account current with the next regularly scheduled automatic payment. ACNH will not debit any amount above that which is due at the time of payment; notice may not be provided to me prior to said payment.

______________________________/_____________________/____________________ Debit/Credit Card Number Exp. Date 3 digit security code

____________________________________/___________________________________ Print Cardholder Name as on card Cardholder Signature as on card

____________________________________/_____________________/_____________

Billing address

City Billing Zip Code

_______________________________/______________________________/_________ Primary Member Signature Printed Name Date




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Documents

acadiananaturalhealth.comacadiananaturalhealth.com/.../2017/...NEW-8152017.docx · Web viewModalities used include nutrition, nutraceuticals, homeopathy ... printed, electronic,