• Adult Intake Form

    Please note that ALL sections must be filled out before you can submit. If a section does not apply to you, please put N/A in box.
  • PLEASE NOTE THAT YOU NEED TO ARRIVE AT LEAST 30 MINUTES PRIOR TO YOUR APPOINTMENT.  IF YOU ARE NOT PRESENT AT YOUR ARRIVAL TIME, YOUR APPOINTMENT MAY BE RESCHEDULED. 

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  • In the past 6 months have you experienced

  • Robinhood Integrative Health, (RIH) believes “Health As It Should Be” involves the integration of all aspects of one’s life by treating the total patient and not merely the symptoms. Some components of integrative care that we utilize to promote optimal health and well being currently do not have the FDA’s stamp of approval. However, at RIH we make sure that there are scientific studies which support all practices we employ.

    We utilize the following tools among others; proper nutrition, tailored supplements, bioidentical hormones, exercise and pharmaceutical medications when needed. We will also offer various courses, programs and lectures which will benefit you as a patient. Additionally, as a service and time savings convenience for our patients, we offer various supplements and products that have been carefully chosen in terms of quality and cost effectiveness available for purchase at our office.

    Presently, some tests that make medical sense may not always be reimbursed by insurance companies. Also, certain medications particularly those that come from a compounding pharmacy, may not be covered by insurance. We are sensitive to the fact that you will have to cover these expenses. With every decision or recommendation that RIH makes, your cost obligations are considered. Ultimately we feel any expense you bear today will be an investment in a future that produces a lifetime of optimal health and well being.

    Please note that ALL first-time follow-up visits MUST be done in person.  We do not allow phone visits for first-time follow-up appointments. 

    THERE IS A 24 BUSINESS HOUR CANCELLATION POLICY- FOR NEW PATIENTS $77, FOR FOLLOW-UP/SICK VISITS $37 AND FOR INFUSION APPTS. $50

     

  • Insurance

    Insurances we do accept are BCBS (all plans except Blue Home, Blue Value, Blue Care and Blue Local, BCBS High Performance Network), Aetna, Cigna, MedCost, and Coventry.

    We have opted out of Medicare and we do not accept Medicaid or certain Tricare policies. We have elected to not have the government dictate how we should care for patients and therefore are unable to accept these policies.

    We are out of Network with United Health Care which means you would pay all costs out of pocket and then you can file with UHC insurance directly.

    For patients who are not covered by insurance or as a result of the above policies, we offer a private contract for a fee of $6 per min or $360 an hour. The average charge for the first visit is $500-$800. This is NOT reimbursable by Medicare or Medicaid.

    Cash labs are NOT reimbursable by a health share insurance company or any third party payer

    Our Practice

    We are problem focused so will not be taking over your primary care. We suggest that you maintain your PCP for routine medical care and sick visits. Due to demand, we are unable to take on every patient with interest in our practice. We take on cases that include symptoms, diseases and challenges that we feel we can most effectively treat based upon our strengths and are unable to take on new patients who are primarily seeking wellness or primary care with an integrative approach.

    Financial Requirements:

    All patients are required to join our patient portal for $60 a year and the payment for that is due on your first visit. The charge will recur every year on the anniversary of your first visit.

    Every patient is required to keep a credit or debit card on file. Our credit card processor is nested in a banking center, so its security greatly exceeds a typical medical office.

    Outstanding balances will be automatically charged to the credit card on file at 90 days.

    Integrative care, such as ours is uncommon and most integrative practices are cash only. We are a hybrid practice, accepting insurances but also acknowledging that there are out of pocket expenses. We are happy to discuss expenses with you prior to treatment.

    If you have a high deductible plan, you can utilize our cash prices for our labs run through LabCorp, otherwise the labs will be filed through Insurance. There are many different tests, that are not available at your PCP's office and not covered by Insurance. We consider them medically necessary for optimal treatment of our patients, but Insurance often does not. These tests do qualify for coverage for HSA's and FSA's, however.

     

  • TESTS NOT COVERED BY INSURANCE

    Your insurance company has deemed that the following tests are not medically necessary and therefore, they will not cover the cost.  However, we feel they are vital to your care.  Your signature below indicates your understanding of this and gives us consent to run the test.  Below is a list of the test/treament that are not covered

    Homeopathic injections
    Comprehensive Stool Analysis
    Cyrex Array
    Food Allergy
    German Lyme Ellispot
    Heavy Metal
    Homocysteine, Cardio
    Igf/Igf Bp3
    I-Spot Lyme
    Kryptopyrole
    Leaky Gut
    MTHFR
    Parasite Stool Kit
    PEMF
    SIBO
    Testosterone Injections
    VAP
    Vitamin B12 Injections
    Yeast Culture (stool)
    Zine Sulfate 0.1% Taste Test
    Oligo Scan
    Doctors Data Test
    Neurotransmitter Test
    Neurocognitive Testing
    Spectracell
    Urinary Hormone Test
    IV Therapy/Ozone
    DNA Connexions
    Adrenal Rhythm Saliva

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  • Credit Card Authorization

  • Thank you for choosing Robinhood Integrative Health as your healthcare provider. As per our office policy and in an effort to keep health care costs as low as possible, we require you keep a credit card on file. This is to your advantage, since health care costs in general can be substantial. By using a credit card, you have the ability to spread the cost over time, making payments to your credit card company, rather than paying the cost all at once. Of course, you can always use and alternative method of payment at check-out if you desire.

    This form authorizes Robinhood Integrative Health to charge your expenses to the card on file unless an alternative method of payment is presented. This includes payments at the check-out window, payments over the phone, payments for purchases in our store and payments that are 90 days in arrears. (You will have received three billing statements).

    Please note: Only one credit card is held on file at a time and it is the last card that you have used.

    If you have any questions, please do not hesitate to call us.

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  • Permission to Communicate

  • So that we may provide you with better quality of care, you have the option of providing us with a list of family and friends with whom we may discuss your health information. You are not required to provide a list but it is helpful. If you do not want us discussing any information with anyone other than yourself please right “None” on the line below. By listing the names below an signing this form I give consent to Robinhood Integrative Health to discuss health information with the people listed below who assist with my care. If I do not want certain information discussed, I have listed it below.

    *THIS FORM WILL STAY IN EFFECT UNTIL YOU NOTIFY ANY CHANGES.

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