Dr Richard M. Hagmeyer D.C, C.F.M.P
Phone 630-303-3869
www.DrHagmeyer.com



Dr Hagmeyer

New Patient Application

Dear Prospective Practice Member,

Welcome to our clinic!

We specialize in helping patients with chronic health problems achieve their highest level of health through our personalized metabolic and nutritional counseling care program.

This application is extensive because we are committed to being thorough with your care. The questions we ask provide important information that will help us determine the kinds of tests that are most appropriate to your individual goals and health challenges.

Please remember to sign the last page indicating you have thoroughly completed this application and understand the terms of the Case Review. Return this application along with any lab and diagnostic test results you have received in the last 6 months.

Email Paperwork to DrHagmeyerPaperwork@gmail.com

Thank you. We look forward to serving you and helping you reclaim your health.

Sincerely,

Dr Hagmeyer, D.C., C.F.M.P

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I acknowledge receipt of the physician's Notice of Privacy Practices. The Notice of Privacy Practice provides detailed information about how the practice may use and disclose my confidential information. LTD

I understand that the physician has reserved a right to change his or her privacy practices that are described in the Notice. I also understand that a copy of any revised Notice will be provided to me or made available upon next office visit follow revision of Notice.

I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at any time by giving written notice of my desire to do so, to the physician. I also understand that I will not be able to revoke this consent in cases where the physician has already relied on it to use or disclose my health information. Written revocation of consent must be sent to the physician's office.

SMS TEXT MESSAGE CONSENT

I consent to receive text message reminders for health promotion, for appointment reminders and other health information such as receiving test results, or that we need to get in touch with you. We might also occasionally send information about special clinics or events we are running that you might be interested in. I will ensure that I keep the practice informed of my up to date mobile number at all times, or if the number is no longer in my possession.

The SMS service should not be solely relied upon, as the responsibility of attending and cancelling appointments still rests with you. Message and Date Rates may apply. Agreement to receive a text message is not a condition of purchasing a good or service. If you no longer wish to receive these text messages please notify the practice in writing. PLEASE NOTE: WE CANNOT ACCEPT INCOMING TEXT MESSAGES.

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The purpose of this narrative is to help me understand everything you have been through concerning your health challenges. On a separate sheet of paper or email, please type the answers to the following questions. This process brings you clarity and makes sure nothing is missed on our end. We want to be the last office that you ever have to consult with.

1. Type out your complete Narrative health history. Be sure to include:
a. Timeline with Rough dates
b. Tests performed/Surgeries, etc.
c. Treatments that worked and treatments that failed
d. Has anything made Your condition worse or cause it to flare up?
e. How long these treatments Helped
f. Why you feel they didn't work
2. Was there a pivotal illness/injury/ Stressor?
when your condition first developed? i.e. (Tick bite, Car Crash, Infection, Abuse, loss of a loved one, Chemical exposure, etc.
3. What diagnosis have other doctor(s) given you for your current condition(s)?
4. Why do you think previous doctors /therapists/health care providers failed you?
5. Why do you think I can Help you? Why would working with my office be different?
6. In your heart of hearts, what do you hope to gain by working with me or my associates?
7. How Long Do you think it will take to accomplish your health care goals?
8. How has your Heath challenge affected friends, spouse, relationships, job?
9. Where Do you picture your health in the next 1-3 years if your health problem is not properly addressed? (be specific)
10. Does Your family Support you working with our office or are you doing this on your own without support?
11. What do you think are some of the things that are wrong with you?
12. How committed are you to your health on a scale of 1-10?
13. Describe a typical day for you? What is your Routine?
14. Has anyone found out what the root cause may be.

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PART I

Please list your 5 major health concerns in order of importance:

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Bristol Stool Scale

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Each day, record all the items you eat and drink. Be sure to include the approximate amount of each item. Your diet may be the key to better health!

Record everything you eat and drink for 7 days. Be as thorough and detailed as possible.

Be as honest as you can be. I am gathering data, not judging.

Don’t change your normal routine. Just record what you are doing.

To measure, simply use hand-sized portions (e.g., 1 palm, 1 fist, 1 cupped handful, 1 thumb) or something else standardized (e.g., baseball, deck of cards). You can use measuring cups or a food scale if you want, but you don’t have to. Record any other notes, such as why you are eating, physical sensations from eating, how you felt after you ate.

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*Please refer to prescribing physician for nutritional interactions with any medications you may be taking.

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NOTICE OF PRIVACY PRACTICES
Richard Hagmeyer, D.C., CFMP
DrHagmeyer.com

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CAREFULLY AND SIGN. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties. and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 4/14/2003 and will remain in effect until we replace it.
We reserve the right to change our privacy practices and terms of this Notice "at any time, provided such changes are permitted by applicable law." We reserve the right to make changes in our practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AN DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment and/or healthcare operations. For example:

Treatment: We may use. or disclose, your health information to a physician or other healthcare provider providing treatment for you.

Payment: We may use and disclose your health information to obtain payment of services we provide you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance. conducting training programs, accreditation, certification. licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization. you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved in Care: We may disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use, or disclose, your health information when we are required to do so by law.

Abuse of Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim or other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health and safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces Personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counter intelligence. and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.

Office Usage: We may also use or disclose your health information to provide you with appointment reminders (such as voicemail messages, phone calls, texts. birthday cards, postcards, or letters).

PATIENT RIGHTS
Access: You have the right to look at, or get copies of, health information with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information.) You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you based on the fees determined by the State of Illinois Comptroller for each page to locate and copy your health information and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer. we will prepare a summary or an explanation of your health information for a fee. Contact us using the information at the end of this Notice for a full explanation of our fee structure. Copies will be provided to you in a timely manner appropriate to process your request. All requests must be submitted in writing to the address at the end of this Notice.

Disclosure Accounting: You have the right to receive a list of instances in which we, or our business associates, disclosed your health information for purposes other than treatment, payment, healthcare operation and certain other activities, for the last 6 years but not before January 5, 2005. If you request this accounting more than twice in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on, our use or disclose, of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your requests under certain circumstances.

Electronic Notice: If you receive this Notice on our website or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
Questions and Complaints: You may complain to us and to the Secretary of Health and Human Services if you believe your privacy rights have been violated.
You may file a complaint with us by writing to our Primacy Official at the address that follows. We will not take any action against you for filing a complaint If you would like further information about our privacy practices, please email: drhagmeyer@gmail.com
I have received a copy of this office’s Notice of Privacy Practices and consent to the use and disclosure of protected health information by Dr Richard Hagmeyer, staff and business associates for treatment, payment, health care operations and additional uses listed above. I have reviewed, acknowledge, and understand the content of the Notice of Privacy Practices.

You May Refuse To Sign This. THIS NOTICE WAS PUBLISHED AND BECOMES EFFECTIVE ON APRIL 14, 2003.

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Affidavit and Case Review Terms

1. I attest to the information provided as being true and complete to the best of my ability.

2. I understand that the Case Review process is used to determine if I am a good candidate for care and the type of care most appropriate for me.

3. I understand that at the conclusion of the Case Review, Dr. Hagmeyer may not accept me as a patient or deem my case one that would benefit from Functional Medicine.

4. I understand that the Case Review does not establish me as a patient under Dr. Hagmeyer's care and there is no doctor-patient relationship or obligation during this case review.

5. Because of the wealth of information and information discussed, I understand that Dr. Hagmeyer' s policy requires my spouse, if applicable, to be included in my Case Review.

6. I understand that the Case Review Fee is not refundable, should I not be accepted as a patient.

7. I understand that missed appointments, no shows or failure to cancel an appointment within 72 hours, will result in a re-scheduling reservation fee of $300.

8. I understand that Dr Hagmeyer does will not prescribe medications and that his practice specialty is in Functional Medicine. Functional Medicines approach to restoring health is founded upon diet, lifestyle changes, nutritional counseling, supplements and natural medicine. I also understand, that Dr Hagmeyer' s care is not to replace my existing primary care physician.

9. I understand that the Case review process is a one-time service to review my case history and the laboratory test results which I have provided with this application. I Understand, no further service or treatment is included with the Case Review Fee.

10. I understand that all laboratory test results, and history must be provided prior to the Case Review process.

11. Prior to my appointment, Dr. Hagmeyer will review the information provided in my New Patient Application.

12. During the Case Review, Dr. Hagmeyer will explain to me and my spouse, if applicable, a detailed report of his findings regarding past test results. This will include Dr Hagmeyer's recommendations for any necessary Functional lab testing or treatment recommendations.

13. I understand that my Case review must be completed within a 30-day period from the time purchased, unless otherwise noted.

14. If I decide to move forward with Dr Hagmeyer's recommended testing, once tests are paid for, by signing below I understand that there are no refunds.

15. Please be sure to make copies of all your paperwork, blood work, etc. prior to submitting records to our office.

16. I understand that since a Dr/Patient relationship is not established at this, if Dr Hagmeyer feels he is not the right fit for my case or I decide not to move forward with testing/care, my file will be destroyed.

17. I understand that Dr Hagmeyer, is unable to return paperwork, testing, CD's, etc.

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Before sending your New Patient Paperwork, be sure you have included the following information by checking each corresponding box. Please include this completed form with your paperwork.