Acknowledgments & consent to treat Please initial each statement. All must be completed before a consult or treatment. Completed intakes are emailed to sarahcruse@proton.me . This website form is not a HIPAA patient portal — established patients use Spruce and Tebra.
I understand that 406 Health Consulting does not cooperate with any insurance companies, Medicaid, or Medicare. If any part of my prescription is to be picked up at a local pharmacy and is not covered by insurance, 406 Health Consulting does not do prior authorizations and does not deal with questions on insurance. I agree to indemnify, defend, and hold harmless 406 Health Consulting, Almalli Wellness, Sarah Cruse, APRN, FNP-BC, and their employees, contractors, and affiliates from liabilities, losses, claims, damages, lawsuits, judgments, penalties, and expenses arising from medical care, services, advice, or treatment rendered. I understand that failure to disclose all relevant information regarding my medical and physical condition may result in harm or injury from medical care or pharmaceuticals provided directly or indirectly by 406 Health Consulting. If I am prescribed any medications, it is my responsibility to keep appointments so there is no lapse. Refills require monitoring. The provider will prescribe refills to last until the next scheduled visit. 406 Health Consulting will not refill prescriptions for anyone not current with labs or appointments. Repeated no-shows or cancellations may result in denial of refills. The practice has the right to refuse treatment. Primary care is offered through 406 Health Consulting; however, underlying health issues may prevent listing this practice as a primary care provider. 406 Health Consulting has the right to refuse primary care. Consent to treat / consult
I hereby consent to evaluation, consultation, diagnostic procedures, testing, and treatment as directed by my provider or her designee. I understand that I may request information on the affiliation of any particular healthcare provider I encounter. This consent is valid for each visit I make to 406 Health Consulting until revoked by me in writing.
Witness signature is completed in the office at your visit.