Lisa M. Zimmermann, M.D.

Transcription

1 Lisa M. Zimmermann, M.D. 776 Shrewsbury Ave. Suite 103 Tinton Falls, NJ PH Fax Welcome to our office!! Please print and sign all forms. Bring them with you on your first office visit. General Information: We do not accept patients under the age of 18. Please call the office for all inquiries. Do not use for this purpose. Because of the high level of services we deliver, we maintain strict policies that must be followed. Much effort, attention to detail and time is needed for us to deliver this type of care. What follows are outlines of these policies and a clarification of what we can and cannot do on your behalf. Please review these policies very carefully. We ask that you do not ask us to make exceptions. If we find you to be noncompliant with office policies or your outlined plan of care without good cause, you will be permanently dismissed from this office.

2 Privacy Policy: Our office is fully HIPPA compliant. If you have not received a copy of our policy we will provide you with a copy upon your visit. You will be asked to sign an agreement stating that you have read and understand the policy. Appointments: This office requires new patients to pay a non-refundable deposit of $225 in order to secure your first visit. The deposit will be deducted from the total due at the end of said visit. Please arrive at the time of your appointment. Patients are seen usually by the time of their appointment and not by those who arrive first. Patients come in for many different reasons other than seeing the doctor. These patients can be called back out of the schedule order. Appointments must be canceled at least 24 hours prior to your appointment. If you cancel the same day or do not show up, your next appointment can be delayed by 6-8 weeks and prescriptions will not be filled until you are seen by the doctor. If persistent cancellations occur, you will be charged the full amount of an office visit in order to reschedule. IV Treatment Appontments: We require a 24 hour notice of cancellation. If you cancel and your treatment is already mixed you will be charge in full. Fees and Payment: All office fees are payable in full at the time of each visit. We do not allow a balance to carry forward. If you have an outstanding balance, it must be cleared before a follow-up visit can be scheduled. Our fees reflect not only the time we spend with you in the office, but also all the time spent on your behalf between visits. This may include reviewing reports, making and receiving calls such as other health care providers, pharmacies etc as well as preparing paperwork.

3 Any copies of reports or files made by our staff will result in a fee of $1.00 per page. Therefore it is advisable for you to bring copies with you. Your Medications, Supplements and Allergy List: Bring with you a list of ALL medications and supplements. This should include the name, strength and how you take it during the course of a day. This is important, as an accurate list is vital to allow delivery of safe and effective care. Primary Physician All patients MUST HAVE a primary care physician who you continue to see on a regular basis. This is a strict requirement as we cater to you specialty needs and will not perform primary care issues such as refilling or prescribing medications not originally prescribed by us. In the event there is an emergency and you are not able to see the doctor immediately you should see your primary caregiver who can then call us if our input is needed. Test Results: All test results are reviewed by Dr. Zimmermann before they are filed. If any significant finding is noted you or your primary physician will be contacted. We ask that you DO NOT call for the results and DO NOT ask us to explain the results by phone or by fax. These matters will be addressed at scheduled visits. We will not mail or fax any test to the patient. Upon request will provide you with a copy at your next visit OR you can open a portal for Labcorp and Quest and retrieve your results.

4 s: Use of is for emergency purposes only and not for asking questions related to prescription renewals, test results, scheduling or supplement needs. Dr. Zimmermann cannot answer questions regarding your insurance issues resulting from lab work or fee schedules. Abuse of this privilege will result in you s not being answered. Prescriptions Renewals: It is the patient s responsibility to remember what medications need to refilled at each follow-up visit. When you come in for your appointment make sure you bring a list of medications that you are on and which ones need to be refilled. If a prescription needs to be refilled between office visits please have your pharmacy fax a refill form to the office at ( ) This is the most effective way of tracking and dispensing medications. DO NOT USE FOR THIS PURPOSE. Disability Forms YOU MUST BE A PATIENT OF THIS PRACTICE FOR A MINIMUN OF 9 MONTHS IN ORDER FOR DR ZIMMERMANN TO CONSIDER DISABILITY. ONLY AFTER CONSIDERALBE REVIEW OF YOUR RECORDS BY DR ZIMMERMANN WILL FORMS BE FILLED OUT AND ONLY IF SHE DEEMS IT NECESSARY FOR YOU TO BE OUT OF WORK. OTHER CONSULTING DOCTORS MAY BE REQUIRED TO SUBMIT LETTERS CONFIRMING THE NEED FOR DISABILITY. There will be a charge of $ for each disability packet filled out by this office.

5 Insurance Appeals This office will not craft or file an insurance appeal. If you are denied by your insurance company it is your responsibility to handle the matter. Cell Phones All cell phones MUST be turned off upon entering the office. NO EXCEPTIONS! ATTENTION ALL PATIENTS Due to the sensitivity of most patients we ask you to respect others. ABOSOLUTELY NO PERFUME OR COLOGNE IS TO BE WORN WHEN COMING TO THIS OFFICE. Thank you! This document may not cover all details of our practice and only serves as a general guide. Because these circumstances change updates may be needed. Patient Signature: Date:

6 Lisa M. Zimmermann, M.D. Name: Date: As part of your current illness, have you had any of the following? Please circle all positives. DATE OF ONSET/DESCRIPTION 1. Tick Bite (deer tick or dog tick) 2. Rash at bite site 3. Rashes at other sites 4. Unexplained fevers, chills, sweats 5. Unexplained weight changes 6. Fatigue, tiredness 7. Swelling around the eyes 8. Swollen glands 9. Sore throat 10. Testicular pain/pelvic pain 11. Unexplained menstrual irregularity 12. Irritable bladder/bladder dysfunction 13. Sexual dysfunction or loss of libido 14. Upset stomach

7 15. Change of bowel function 16. Chest pain 17. Shortness of breath, cough 18. Heart palpitation or blocks, pulse skips 19. Joint pain or swelling 20. Muscle pain or cramps 21. Twitching of the face or other muscles 22. Headaches 23. Neck creaks, cracks or stiffness 24. Stiffness of the joints or back 25. Tingling numbness burning or stabbing sensations. 26. Facial paralysis (Bells Palsey) 27. Eyes/vision double, blurry, pain, increased floaters 28. Ears/Hearing-buzzing, ringing, pain 29. Dizziness, poor balance, increased motion sickness 30. Lightheadedness, wooziness, Difficulty walking 31. Tremors 32. Confusion, difficulty thinking

8 33. Difficulty with concentration or reading 34. Decreased short term memory 35. Disorientation, getting lost 36. Difficulty in speech 37. Mood swings, irritability, depression 38. Disturbed sleep, too much, too little, early awakening 39. Exaggerated symptoms or worse hangover from alcohol Have you had a blood test for Lyme disease? YES NO When Have you received antibiotics in the past year? YES NO WHEN If so what type SIGNATURE

9 Lisa M. Zimmermann M.D. Payment Policy EACH PATIENT IS FINANCIALLY RESPONSIBLE FOR THE PAYMENT OF ALL SERVICES OF SUPPLIES PROVIDED AT THE TIME OF EACH VISIT. THIS OFFICE DOES NOT PARTICIPATE WITH ANY INSURANCE COMPANY. Each patient will be provided with a receipt, commonly referred to as a superbill. This form meets the legal requirements of the Healthcare Financing Administration which mandates the use of the International Classification of Disease, 10 th revision, Clinical Modification (ICD-10CM), as the medical coding system physicians must use to designate diagnosis and treatment. Further, this superbill can be attached to any of the healthcare claim forms and be submitted for processing. This is entirely sufficient by law for reimbursement by your insurance company. It is the patient s responsibility to submit the claim to their insurance company for reimbursement. If the Doctor should receive fees on your behalf, including payments made directly by insurance companies, the Doctor will deduct any and all monies due for services performed on your behalf.

10 Lisa M. Zimmermann M.D. 776 Shrewsbury Ave. Tinton Falls, NJ Fax: Patient Name Date of Birth Age Sex Marital Status Address City State Zip Home Phone Cell Phone Soc. Security # Driver Lic # Previous Doctor If Minor Parent/Guardian Address Home Phone Cell Emergency Contact Phone Patients Employer Phone Address I understand I am responsible for the balance of my account for any professional services rendered. I have read all information and completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify this office of any changes in the above information. Patient Signature Date.

11 Lisa M. Zimmermann,M.D. 776 Shrewsbury Ave. Suite 103 Tinton Falls, NJ Dr. Zimmermann does not treat patients based on CDC guidelines therefore, treatment protocols are individualized; and can be a combination of traditional prescription medications, herbal and homeopathic regimens. Dr. Zimmermann treats each patient with a personalized plan. Patients will be asked to adhere to dietary and other changes to ensure effective treatment. I agree to the above treatment parameters and choose to be treated. Patient signature Date

12 Lisa M. Zimmermann, M.D. 776 Shrewsbury Ave Suite 103 Tinton Falls, NJ To: RELEASE OF MEDICAL RECORDS I hereby authorize and request you to exchange records and information with Dr. Lisa Zimmermann. NAME: ADDRESS: CIITY: STATE: ZIP: PATIENTS SIGNATURE: PRINT: DATE:

13 Lisa Zimmermann, M.D. 776 Shrewsbury Ave. Suite 103 Tinton Falls, NJ Lisa Zimmermann, M.D. is an Out of Network Practice, as pertains to all insurances. As a Medicare patient, I will be financially responsible for all tests Dr. Zimmermann deems necessary for my continued treatments and evaluations. I understand that I can request my Primary Care Physician (if they are willing and participate in Medicare) to write prescriptions for all tests Dr. Zimmermann requires. Patient Signature Date

14 THE FOLLOWING MAY OR MAY NOT APPLY TO YOU Bioresonance Analysis of Health (BAH) Testing BAH testing is performed by Dr. Lisa Zimmermann for the purpose of diagnosing, identifying and evaluating dysfunctions of the body. The tests are done in our office with a follow-up communication to the patient within one week of the test. FIRST TIME TESTS WILL BE FOLLOWED UP WITH AN OFFICE VISIT TO REVIEW THE RESULTS. Once the evaluation is complete the patient will be informed of the treatment plan and protocols to follow. If Dr. Zimmermann determines that IV treatment is necessary, we will schedule appointments according to her plan. This may require scheduling one or more treatments per week, at a specific time and day. It is imperative for the patient to clear their personal schedule to receive the treatments in the order in which they are designed. This office cannot insure the efficacy of the course of treatment if it is altered by a skipped appointment. MANDATORY BAH/TREATMENT PROTOCOL: The patient will have a BAH test at the end of 1 st segment of treatment and again at the end of all treatments. At that time a mandatory office visit will be scheduled with Dr. Zimmermann for a comprehensive review. Dr. Zimmermann, at her discretion, will also schedule regular blood tests (chem profile etc.) between office visits. INITIAL BAH $350 BAH RETEST $125

15 **ALL PATIENTS HAVING A BAH MUST PROVIDE A LIST OF ALL MEDICATIONS AND SUPPLEMENTS YOU ARE CURRENTY TAKING. DR. ZIMMERMANN CAN NO LONGER DO A BAH TEST WITHOUT THIS INFORMATION. **ALL PATIENTS HAVING A BAH MUST PROVIDE THEIR ADDRESS FOR US TO CONTACT YOU REGARDING RESULTS. THANK YOU!