Dr. Joel Gator Warsh is a medical doctor with substantial experience in medicine. While the recommendations on this site represent the opinion of doctors and other health professionals and are based upon the best of their knowledge, experience, and training as to safety and effectiveness, these recommendations have not been reviewed by the U.S. Food and Drug Administration.
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Office Policies – Last updated 9/20/2022
Thank you for choosing Integrative Pediatrics and Medicine (IPM) for your child’s medical care. We are providing you with the following information to help you understand our office policies including our insurance and billing policies. Any future office policy updates will be made on our terms of service on our office web page (IntegrativePediatricsandMedicine.com). The terms of service will serve as the most up to date office policies.
You must show your current insurance card at every visit. This is to protect you from receiving a bill because we did not have correct insurance information. We will attempt to validate your insurance benefits at time of service and alert you to any problems. “If we cannot validate your coverage, we will assign your account to self-pay status. We will request full payment either prior to, or after your visit. If we learn later that your insurance was not active at the time of your visit, you will be responsible for the full payment of the visit.
You must pay your co-payment at the time of the office visit. Our contracts with insurance companies require us to collect your co-pay at the time of service. We accept cash, credit cards, and checks as forms of payment. In the event a personal check is returned unpaid from your bank, your account will be charged with a returned check fee of $20, and your account may be placed on a “cash only” basis for one year.
Know your insurance benefits. Your policy is a contract between you and your insurance company, even if your employer provides it. There are many subtle differences in insurance policies, and employers frequently change coverage and co-payments. You are responsible for knowing what services are covered (and how often, in the case of well
visits), and how much of the cost is your responsibility. You will be responsible for any
portion of services that your insurance doesn’t cover, or for which you have a deductible
that has not yet been met. If your insurance comes back to our billers as invalid or not active, our office will place a hold on your credit card for the cash price of anything completed at all prior visits.
You should also be aware of where your insurance wants you to go for any lab or radiology procedures, so that in an urgent situation, you are seen at the appropriate facility and will not receive a bill. Each insurance company is different and plans change all of the time. You are responsible to know your plan and check before any item is completed. We aim to follow best practices and are not responsible for any laboratory or radiology fees when an insurance company does not pay or places payment to deductible. We are not aware of which labs will be covered when. This information changes all the time and varies by plan and each submission. YOU ARE SOLEY RESPONSIBLE FOR ALL LAB FEES. If you are concerned about high laboratory or radiology fees, check with your insurance before you complete the tests.
If your child is covered by more than one insurance policy, be sure you know which is considered primary. We must submit claims to the appropriate carrier(s) in the right order.
Our Collection Procedures
If your account is self-paid, all services must be paid for at the time of your visit. This may include situations where we cannot validate active coverage with your insurance carrier. In such cases, we will collect payment at time of service and refund any amounts subsequently collected from your carrier.
If you have valid coverage with a participating insurance carrier, we will file an insurance claim within five business days of your date of service. If there are any problems with this submission, we will notify you immediately, and request your prompt assistance with any conditions under your control that are causing a delay in processing. If your insurance carrier does not respond within 30 days, we will submit a second claim. If your insurance carrier does not respond to our secondary submission, payment will become your responsibility. You will need to contact your insurance carrier if you think it is responsible for payment. We will expect payment from you at that time.
If your participating insurance policy is subject to routine deductibles and/or coinsurance that cannot be collected on the date of service, we will charge your credit card on file as soon as your carrier provides an Explanation of benefits (EOB) designating your financial responsibility for the claim as set out in our Credit Care on File (CCOF) policy. We will charge your credit card if, in our sole opinion, the claim was adjudicated normally. If the claim is denied and we feel there may be an issue, we will contact you to resolve the situation before collecting any amounts indicated as due or non-covered services. If the claim cannot be resolved with your insurance company, then you are financially responsible for all charges.
If you are insured by a non-participating insurance carrier, we will expect payment
from you at time of service, and it will be your responsibility to submit any claims to your insurance company for direct reimbursement to you. We will provide you with the
appropriate information to assist you in this process. We are not contracted with any HMO plans, Kaiser or Medicare/Medicaid.
All statements are due on receipt of your EOB. We will charge your credit card on file for the balance which you are legally required to pay.
Unfortunately, insurance does not cover most administrative costs to the practice and the costs to bill and collect payments are significant. To offset these costs to you, we offer CCOF which makes this process quick and simple.
If charges are unable to be collected you will be informed with a letter/email informing you that our relationship is subject to cancellation after 30 days of urgent and emergent care. All further services will be provided on a cash-only basis.
We reserve the right to send your account to our collection agency after all internal
efforts to obtain payment have been exhausted. You are then responsible for any collection costs in addition to your outstanding bill. If you are presently in collection, the practice will use its discretion as to providing you with further treatment or asking you to find another physician.
If you have a newborn or newly adopted child, congratulations! Your child is covered for the first 30 days by the mother’s policy, regardless of which parent will provide ongoing insurance coverage. You should contact your carrier as soon as feasible to add the new child to your policy. Permanent coverage must be in place before the automatic newborn coverage expires. You must have your child added to your policy by the one-month visit and should have an insurance card to present at that visit. If you have not received an insurance card, contact your insurance company prior to the visit to verify coverage and get an active insurance ID number. If you do not have active coverage your visit may be rescheduled/delayed or you may be personally responsible for the bill.
We are more connected than ever with technology. Our office uses email and texting service frequently. Please do not, under any circumstance email, text or call for an emergency. Please call 911. While we do strive to return all calls and messages as promptly as possible, you should never assume that our office will receive an email, text or call right away in an emergency setting. Call 911 or go to the nearest emergency department immediately.
Any message sent online is never 100% secure. IPM does its best to protect your health records and follows HIPPA standards. Please do not email or text any sensitive information that you would be concerned could be stolen by a hacker as no one can guarantee that messages will never be stolen. Hospitals, banks and other businesses have unfortunately been “hacked” in the past so there is a risk, albeit very low that this could occur. I release IPM from all liability for any email, phone, text, call or other method of communication and understand that I should not send sensitive information via an unencrypted route.
I agree to have my email address added to the Integrative Pediatrics email list so that I can be kept uptodate on the latest information from the office and doctors. My information will never be sold or given to a third party.
Pursuant to Assembly Bill (AB) 1278, physicians are required to provide a notice to their patients regarding the Open Payments database (Database), which is managed by the U.S. Centers for Medicare & Medicaid Services, or CMS.
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.
When you call and schedule an appointment, time is reserved especially for you and no one else. Since the appointments are often longer than standard office visits, cancellations are significant interruptions to the clinic. Thus, a minimum of 1 business days (24h) notice is required for cancellations of new patient first visits and for well check-ups of existing patients. You may be charged for a new patient visit upfront to hold your appointment space. No shows will be charged for missing a first visit.
We also require that all new patients complete and return their new patient paperwork no later than 7 days prior to your appointment (especially for new consults with extensive medical histories that our physicians need to read through to appropriately plan for your visit). If the new patient paperwork is not received, we may have to reschedule the appointment and cancellation fees may be applied.
A no-show fee of $85 will be charged for no-shows or late cancellation. After the first occurance, a no-show fee of $125 will be charged. This fee is subject to increase in the future. Continued no show or late cancellation or showing up late for appointments is grounds for discharge from the practice.
Cancellation of a visit must be made at least 24 business hours prior to your visit including telemedicine visits. If the visit falls after a weekend of holiday, the cancellation must be made 24 business hours prior, ie on Friday for a Monday visit. This is to ensure that all time-slots are filled for patients and slots are not taken that could otherwise be used by a patient in need of a visit.
If you arrive to a visit and your insurance is not active, you may pay cash for the visit or reschedule and late cancel fees will apply. You are responsible to ensure an active insurance.
Time is reserved especially for you and no one else. If you are going to be late, please call us so we can discuss the best option for your visit. Late patients can be a significant interruption to the clinic, especially given the nature of our practice where we have some extended consults on complicated patients. Anyone who arrives later than their scheduled appointment start time, may be asked to reschedule their visit. For a check-up, a shortened visit may be allowed, but the visit should not go into another patient’s time slot. The office will accommodate as possible. Cancellation fees may apply.
Multiple late appointments or cancellations without reasonable cause are grounds for dismissal from the practice.
Motor Vehicle Accident
If your child is seen in our office for concerns related to a Motor Vehicle Accident this does not get processed through your health insurer. Please provide us with the appropriate Motor Vehicle Insurance information and the claim number at the time of the visit to ensure that you do not personally become responsible for the bill.
By signing below, you are agreeing to our office policies for yourself and all of your current and future children which are patients of IPM.
I understand and acknowledge the Integrative Pediatrics and Medicine Studio City and all of its doctors are opted out of medicare and do not accept Medicare. I may not submit any claims to medicare and will not be reimbursed by medicare for any visit or in office procedure. Patients with medicare may pay cash rates to the office.
I understand and acknowledge that IPM uses secure telemedicine technology. I consent to the use of telemedicine and understand that a telemedicine visits is considered the same as an office visit but is completed online instead of in the office. I can choose to go into the office for any visit and I understand that telemedicine is a convenience provided by the office for your benefit. Standard visit charges apply. If you feel something must be seen in person, please book an in person visit.
Informed Consent for Integrative Medical Treatment
As a patient or parent/caregiver of a patient, I have the right to be informed about my condition and recommended care. This disclosure is to help me become better informed so I may make the decision to give or withhold my consent to undergo care after having had the opportunity to discuss potential benefits, risks, and hazards involved.
I hereby request and voluntarily consent to examination and treatment with integrative medical care, possibly including homeopathic medicines, vitamins, minerals, supplements, IV therapies, ozone therapies, injections, detoxification treatment modalities, lab testing, nutrition recommendations, etc. for me (or for my family for whom I am legally responsible) by IPM and/or other licensed medical providers, or those working or training at the office who now or in the future may treat me while employed by, working or training with, or serving for back up for the aforementioned. I can request that students not be included in my evaluation and treatment. I can request further explanation of the procedure or treatment, other alternative procedures or methods of treatment, and information about the material risks of the procedure or treatment.
Although nutritional, herbal and homeopathic supplements, compounded IV’s/injections, ozone therapies, bioidentical hormone replacement therapies. Have been widely used in Europe and the US for years, I understand that they have not been well studied by the US Food and Drug Administration. I understand that the U.S Food and Drug Administration has not fully evaluated or approved these modalities.
I understand that, as with medications, hormones, nutritional supplements, herbal, and homeopathic remedies, ozone, nutritional IV therapies and injections may exhibit some side effects in certain sensitive individuals, may interact with certain allopathic medications or lab tests, or show symptoms, due to certain pre-existing disease conditions. I do not expect the medical provider to be able to anticipate and explain all risks and complications, and I wish to rely on the medical provider to exercise judgment in recommending the dietary supplements, medications, and treatment, that the medical provider feels at the time, based on the facts then known, is in my best interest. I understand that if I do not take the supplements or treatments as recommended, I may not get the desired result or may increase chances for an adverse effect.
It is my responsibility to keep my medical providers (whether in IPM or outside of IPM) up to date with all of the current medications and supplements that I am taking, so that he/she can make the best informed recommendations for my care.
I have the opportunity to ask questions and discuss with my provider to my satisfaction:
- my suspected diagnosis or condition
- the nature, purpose, and potential benefit of the proposed care
- the inherited risks, complications, potential hazards, or side effects of the treatment or procedure
- the probability or likelihood, of success
- reasonable available alternatives to the proposed treatment or procedure
- the possible consequences if treatment or advise is not followed and/or nothing is done
I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment.
I understand that integrative medicine, evaluation and treatment may include, but is not limited to: collecting specimens for laboratory evaluation, ordering diagnostic imaging, prescription of certain medications and nutritional supplements, IV therapy, medical ozone treatment/therapy, bio-identical hormone replacement therapy, injections, counseling, dietary therapies, infrared sauna, colonics, and homeopathic or other alternative remedies.
I understand that the medical providers at IPM have been trained in a diverse range of diagnostic and treatment options. I understand that IPM practitioners are highly specialized and base decisions upon evidence-based medicine, including functional medicine and holistic principles. As such, they may recommend different tests; may interpret standard tests differently; may propose different treatments, or may administer standard treatments differently than most conventional physicians. Many perspectives exist in medicine and in some cases, there may be a disagreement among qualified medical experts. Care rendered may therefore be seen by some as outside standard of care or medically unnecessary. Diagnosis and treatment may include some services that are considered non- traditional, nonconventional or alternative medicine. These services may not be recognized as standard medical practices and may be considered by insurance companies to be experimental or investigational. Along with training, the rationale for these differences is based on clinical experience and ongoing continuing education in evidence based functional and integrative medicine.
You and your family are under no obligation to undertake any treatment or procedure that you are not comfortable with.
By signing this form, I acknowledge I have carefully read, or have had read to me this document, and understand the above consent. I give my permission and consent to care and authorize medical treatment by IPM and their staff, and I am fully aware of what I am signing. I intend this consent form to cover the entire course of treatment for myself, and all family members cared for at IPM for any present and for any future condition(s) for which I seek treatment.
Non-Covered Services Waiver
We pride ourselves on providing only the highest quality care for your child and family and do this by following many of the American Academy of Pediatrics and American Medical Association clinical guidelines and other trusted sources for evidenced-based clinical outcome information.
However, insurers rarely keep pace with guidelines, or want to cover services related to meeting these clinical recommendations. In fact, insurance company rules and policies change all the time. As prompt and appropriate treatment of your child is of primary importance to us, we ask that you sign a ‘waiver’ giving us permission to perform screenings, tests and non-covered services as we, your trusted providers of care, deem necessary.
Snellen Testing. This is a simple screening performed with the use of a Snellen eye chart used to measure visual acuity on older children.
For Snellen tests the discounted price is only $15.00
Photoscreen Eye Evaluatoin
As we consider these to be important tests for your child, and will routinely perform them at annual well visits, if your insurer does not cover the charge, we will significantly discount the amount. Photoscreen test discounted price is $40.00.
Otoacoustic Emissions testing (or OAE)
This is an important hearing test and can be used on newborns through adulthood. It does not require a soundproof room or the ability of the child to understand instructions or respond to sounds, which makes it a much more accurate screening tool for identifying on hearing issues at any age.
Not only do we believe that hearing screens should be performed every year, but testing is required for most preschools, public and private schools, and for sports. As we consider this to be an important test for your child, and will routinely perform it at annual well visits, if your insurer does not cover the charge, we will significantly discount the amount to $15.00 per test.
Developmental screening (including standard pediatric developmental screening done at well-visits, Connors forms, Edinburgh post-partum depression screening, etc) are very important in the assessment of any development delays or potential problems. As we consider these to be important tests for your child, and will routinely perform them at annual well visits, if your insurer does not cover the charge, we will significantly discount the amount to $10.00 per test.
In-office lab tests
Often, patients want to know as soon as possible if their child has the flu, strep, Coronavirus etc. We can effectively and efficiently determine that by performing in-office testing. Many insurers do not pay for in-office testing because they have contracts with external labs to provide these services. However, sending tests out to external labs results in waiting days for results that we can provide to you much more quickly (in some cases, within minutes or overnight). We believe it is important to treat your child as quickly as possible, and therefore offer these services in-office.
In-office labs and fees include:
** Price may change depending on testing used
All tests prices are subject to change based on upon increased test pricing or increased costs.
Standard cash pay visits range from $150-$400 and vaccines range from $50-$400. If you have specific questions about costs. Please call our office for full details.
|Fee schedule (Last updated 12/7/22)||$$|
|Supplements||prices vary. Ask in office|
|Office visit/sick visit (15 min)||150|
|Consult (30 min)||200|
|Well check (new patient first visit)||250|
|Membership Dr. Tiff (new patient)||625|
|Membership Dr. Tiff (Returning patient)||625|
|Membership Dr. Joel (new patient)||900|
|Membership Dr. Joel (returning patient)||625|
|Missed appointment/Late cancel||75|
We follow the CDC and AAP guidelines for vaccination. We offer vaccines on the recommended schedule. If your insurance company does not cover a recommended vaccine, you will be responsible for the cost of the vaccine and administration. Some insurance companies will place vaccine costs to deductible. You are responsible for checking with your insurance company to see if this is the case. We will offer vaccines as laid out in the standard schedule. Vaccine prices vary. You can inquire with our staff if you have questions on any specific vaccine. If we do not carry a specific vaccine that you wish to obtain, you can get it at a travel clinic or at the department of public health.
Basic forms (as deemed by IPM staff) will be completed for a fee of $20 per form. Complicated/extensive forms will be completed for $40 per form.
Urgent/Rush forms (needing completion with 24 hours) will incur a charge of $40.
Complicated referrals such as for Children’s Hospital Los Angeles will be a charge of $40
Well checks are often covered by insurance companies in full (unless there is co-insurance). It is important to note that all insurance companies are different and some put varies items to deductible such as vision screens, hearing screens, developmental screens etc. There is no way for this office to know which insurance will put what to deductible. We follow best practices and AAP guidelines. If your insurance places these items to deductible, it is your requirement by law to pay.
It should also be noted that insurance often only pays for basic well care. Anything outside of that is often coded as a well plus an office visit. For example, if you wish to discuss a new diagnosis of asthma and asthma treatment, if you come in for a well check but also have a cold you wish for us to check, if we spend 10 minutes discussing developmental concerns, if you need radiologic or laboratory testing or any diagnosis other than well child care is discussed, the visit will often be coded as well and office visit. Office visit fee portions may go to deductible. We will often not add on the office visit for simple basic questions as we do not wish for you to be scared to ask those questions when you come in. But if extended periods of time are used to discuss any topic outside of general well care, an office visit code will be added as required by insurance and there may be fees that go to deductible.
No Insurance/Insurance take backs
You are responsible to ensure that your insurance is valid and up to date. Though we go through significant effort to check on the validity of your insurance through our EMR, sometimes the insurance will have different information then we are provided. Should we submit a claim to insurance and it come back from insurance that your insurance is not valid for the date of service, even if you think it should be valid, you will be charged the cash price for the visit and any items completed at that visit. At least a $150 hold will be placed on your card for all visits that are denied and the cost of any vaccines or procedures done on that visit will also be placed on a hold on your credit card on file. Similarly, if an insurance claim is paid, but at a later date, our office receives a notification from your insurance of a take back of money paid because of lack of insurance due to your error or their error, at least a $150 hold will be placed on the card on file for each DOS and the cost of any procedures or vaccines will be charged. You most certainly can discuss this with your insurance and our office will help to the best of our ability to get these claims paid. If we are paid, at a future date by your insurance, any cash collected will be refunded. You are responsible for all charges and fees. This includes take backs by insurance months or years after the DOS because of their mistake. If insurance tells us that you do not have coverage for a DOS, then cash charges will be applied. If at a later date, adjustments are made, refunds will be done for the full cash price collected. There are no exceptions to this rule.
Additionally, if you leave the office for any reason, if there is a significant balance on your account or there are unpaid visits, a hold will be placed on your card for all visits and procedures/vaccines. This will be refunded upon payment by insurance.
Waiver Form Acknowledgement of Receipt
I acknowledge receipt of the Waiver List and have been informed of, and hereby attest that I fully understand my financial responsibility for any balance resulting from non-covered services, or services not covered in-office, by my insurer as detailed on this form or as discussed on day of visit for myself or any current or future family members which are patients at IPM. I agree to pay the amount of the charge as stated herein, in the event that my insurer does not pay for these services.
Insurance Claim Denials
I understand that our billing department does their best to file and complete claims in a timely fashion. It is your responsibility to make sure your insurance is active. If for any reason your claim is denied, you are responsible for the full amount of the visit and any procedures completed at the visit. You will automatically be charged on your credit card on file as soon as the denial occurs. I authorize Integrative Pediatrics and Medicine to charge my card for any outstanding charges or denied visits. I also understand that claims must be submitted in a timely fashion. Each insurance has a different length of time in which claims can be submitted. If my insurance is inactive beyond the timely filing limits, I will be responsible for all charges. The billing department at IPM will work to complete all claims as reasonable and able and will resubmit claims as requested. After 6 months from the date of service, if a claim is still open and continued to be denied by your insurance, we can complete superbill at $5 per claim and provide to you to continue your dispute with your insurance. After 6 months from your date of service, if a claim is not completed and the insurance is continued to be denied or inactive, any further appeals with insurance will the responsibility of the patient. It is your responsibility to make sure our office accepts your insurance. We do our best to validate all insurance but this responsibility is solely yours. If you provide a plan that we do not accept such as an HMO, it may not be apparent for many months until appeals are filed with your insurance after claims deny. Make sure to double check with your insurance that we accept your insurance. If you are found to have an insurance we do not accept, you will be responsible for all outstanding charges for all visits and procedures and will be charged on your credit card on file immediately after this becomes apparent.
EXPRESS PAY/CREDIT CARD ON FILE – CONSENT FORM
In order to avoid having to charge statement billing fees of $25 per bill for each claim, Integrative Pediatrics and Medicine (IPM) requires that all families leave an active credit card on file. This can be used for all charges including co-payments, balances, fees, etc. Leaving a credit card on file (CCOF) makes check out faster, allows online payment, allows for easy refunding of any payment overages, reduces fees to you and helps support IPM stay focused on delivering care rather than chasing down bills.
The current healthcare market has resulted in insurance policies increasingly transferring costs to you, the insured. Some insurance plans require deductibles and copayments in amounts not known to you or us at the time of your visit. Similar to hotels and car rental agencies, you are asked for a credit card number at the time you check in and the information will be held securely until your insurance company has paid their portion and notified us of the amount of your share. If there is a balance, your credit card will be automatically charged upon adjudication of your claim for any portion you are legally responsible to pay.
Several weeks after your visit, you and our office will be notified by mail or email from the insurance company of your balance on your explanation of benefits (EOB) which will serve as your receipt. After receipt of the EOB, we will charge your card on file for your responsibility as defined by the EOB once we receive our copy of the EOB. For very large charges, we may send a courtesy call and/or email 24-48 hours prior to charging the card on file, to make sure you are aware you card will be charged and to allow the chance to arrange alternate payment methods if desired. Our billing department will send you a receipt of any charges that are made to your card if requested. If during the claim adjudication process we receive any unexpected information regarding your payment responsibility, we will promptly notify you to give you an opportunity to address with your insurance company before we charge your credit card.
Your information is secure. IPM does not store any credit card information on our systems or in our office. The data is held by a secure third party that specializes in Express pay/CCOF for medical practices across the country. We use a service, Instamed, which gives us the ability to swipe your credit card, debit card or health savings account card and accept a payment in the office at the time of service or at a later date.
It is your responsibility to inform us of a card change/expiration. Any costs for declined cards may be added to your bill. If you reverse charges to your card that are not due to our error, we may add late and collections fees of $50 to your account. Should there be any changes to your financial responsibility, cards can easily be credited back through Instamed. Please be assured that this payment method in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment. If you have any questions about this payment method, do not hesitate to ask.
I understand that once my insurance has paid for their portion of my care, I will receive an Explanation of Benefits (EOB). The insurance plan EOB will state any balance remaining to be paid by me. I agree that Integrative Pediatrics and Medicine may charge my credit card on file for the balance due when they receive a copy of the EOB and can charge my card on file for outstanding balances from the EOB or any outstanding balances or fees at the office. By signing below, you are agreeing to keep a credit card on file for future payments for yourself and all family members who are patients at IPM.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
We are required by State and Federal laws, including the HIPAA rules, to safeguard general and health-related information about you. We have a Notice of Privacy Practices that explains how your protected health information is handled and how we may use and/or disclose your protected health information. The Notice of Privacy Practices is provided to patients (and/or their authorized representatives) upon request, when they first become our patient. I agree to allow IPM to share medical information between practitioners for medical use. I also acknowledge that IPM may transmit medical information, including vaccines records, to CAIR immunization registry and schools upon request.
We are asking you to sign this form to show that we offered you a copy of our Notice of Privacy Practices. Copies are available upon request from our staff. By signing below you are only acknowledging that you were offered or received a copy of the Notice of Privacy Practices. You may refuse to sign this acknowledgment if you wish. You are not making any statement about the content of the Notice of Privacy Practices or about your agreement or disagreement with any portion of it.
I acknowledge that Integrative Pediatrics and Medicine (IPM) has offered or provided me with a copy of its Notice of Privacy Practices, which describes how medical information about me may be used and/or disclosed, and how I can access this information.
I understand that if I have questions or complaints I may contact: Privacy Officer Dr. Joel Warsh. I also understand that I am entitled to receive updates upon request if IPM amends or changes its Notice of Privacy Practices in a material way.
I acknowledge and understand that all vaccine administered at IPM are automatically uploaded through the office EMR to the California Immunization Registry (CAIR). Some laboratory testing is also required to be submitted to Public health including lead testing. Information on testing results will be shared with public health or other organizations as legally required by California rules and regulations.
Consent To Treat Minor
I hereby give consent to Integrative Pediatrics and Medicine (IPM) to perform any radiology or lab testing, examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care as deemed advisable by a licensed physician, practitioner as well as any assistant on the staff of IPM or in the office of IPM.
I understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required. I also understand that integrative medical procedures and treatments often fall outside of standard of care of regular medical treatments. I agree to incorporate integrative medical care into may families medical care and that I am free to leave IPM and join a conventional medical practice.
Common Diagnostic Procedures: e.g. Laboratory bloodwork, radiology, diagnostic imaging, thermographic imaging, allergy testing, environmental testing, hormone testing, and other specialty labs.
Physical Examination: Screening Physical Exams may include any of the following: Skin & Dermatology; Head, Ear, Eyes, Nose & Sinuses & Throat; Face & Neck; Lungs & Pulmonary; Chest & Cardiovascular; Abdominal; Hands, Arms & Lower Limbs; Reflexes; Motor Skills; Back and Spine; Cranial Nerves; Male Genitalia, Prostate & Rectal Exams; Female Genitalia, Gynecological & Breast Exams; Mini-Mental Status Exams; Nutritional Exams.
Minor Office Procedures: e.g. Wound dressing, ear cleansing, and wart treatment.
Medicinal use of Nutrition: e.g. Therapeutic nutrition, and nutritional supplements.
Physical Medicine: e.g. Therapeutic ultrasound and electrical muscle stimulation, manipulative therapy, muscle stretching/massage, constitutional hydrotherapy.
Botanical Medicine: Botanical substances may be prescribed as teas, alcoholic tinctures, capsules, tablets, creams, plasters or suppositories.
Homeopathic Medicine: The use of highly dilute quantities of naturally occurring plants, animals and minerals to stimulate the body’s healing responses.
Detoxification: e.g. Heavy metal and environmental detoxification.
Chinese Medicine: e.g. Acupuncture, electro-acupuncture, cupping, electrical stimulation, TDP lamp, MIT Therapy, Chinese herbal medicine.
Lifestyle Counseling and Hygiene: e.g. Diet therapy, promotion of wellness including recommendations for exercise, sleep, stress reduction and balancing of work and social activities.
I recognize the potential risks and benefits of these procedures as described below:
Potential Risk: Allergic reactions to prescribed medications, herbs and supplements, side effects of natural medications, inconvenience of lifestyle changes.
Potential Benefits: Restoration of health and body’s maximum functional capacity without the use of drugs or surgery, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease of its progression.
Notice to Women: All female patients (or parents of female patients) must inform the doctor if they know, suspect, or may be pregnant as some of the therapies used could present a risk to the pregnancy and fetus.
This consent is given to any and all such diagnoses, treatments and hospital care which a licensed physician at IPM recommends.
With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Integrative Medical Specialists or any of its personnel regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. I understand Integrative Medical Specialists will keep a record of the health services provided to me. This record will be kept confidential and will not be released to others unless directed by myself or my representative in writing, or unless it is required by law. I understand that I may look at my medical record and can request a copy of it by paying the appropriate fee. I understand that my medical record will not be kept more than ten years after the last day of my last treatment. I understand that any questions concerning this form can be asked of the doctor.
This authorization will remain in effect until revoked in writing by the parent or legal guardian of all current and future family members who are patients of IPM.
Updates to Office Policies
I understand and acknowledge that the IPM office policies will be updated in the future as needed. If any changes are made online to the office policies, an email will be sent out to all patients of the office. It is your responsibility to make sure you are receiving office communication through emails.
Immunization Registry Notice to Patients and Parents (original form can be found https://cairweb.org/docs/CAIR_Disclosure_Eng.pdf)
Immunizations or ‘shots’ prevent serious diseases. Tuberculosis (TB) screening tests help to determine if you may have TB infection and can be required for school or work. Keeping track of shots/TB tests you have received can be hard. It’s especially hard if more than one doctor gave them. Today, doctors use a secure computer system called an immunization registry to keep track of shots and TB tests. If you change doctors, your new doctor can use the registry to see the shot/TB test record. It’s your right to limit who is able to access your records in the California Immunization Registry (CAIR).
How Does a Registry Help You?
Keeps track of all shots and TB tests (skin tests/chest x-rays), so you don’t miss any or get too many Sends reminders when you or your child need shots
Gives you a copy of the shot/TB record from the doctor
Can show proof about shots/TB tests needed to start child care, school, or a new job
How Does a Registry Help Your Health Care Team?
Doctors, nurses, health plans, and public health agencies use the registry to:
See which shots/TB tests are needed Prevent disease in your community Remind you about shots needed Help with record-keeping
Can Schools or Other Programs See the Registry?
Yes, but this is limited. Schools, child care, and other agencies allowed under California law may:
See which shots/TB tests children need
Make sure children meet requirements for shots and TB tests needed to start child care or school
What Information Can Be Shared in a Registry?
patient’s name, sex, and birth date limited information to identify patients
parents’ or guardians’ names details about a patient’s shots/TB tests or medical exemptions
What’s entered in the registry is treated like other private medical information. Misuse of the registry can be punished by law. Under California law, only your doctor’s office, health plan, or public health department may see your address and phone number. Health officials can also look at the registry to protect public health.
Patient and Parent Rights
It’s your legal right to ask your provider:
to prevent other providers and schools from accessing your (or your child’s) registry records not to send shot appointment reminders
for a copy of your or your child’s shot/TB test records
who has seen the records and to change any mistakes
No action is needed to be part of CAIR. Other CAIR providers, schools, and health officials automatically have access to your or your child’s records.
If you want to limit who sees your or your child’s records:
- Check with your provider to see if they can lock your records in CAIR
- If your provider can’t, complete a Request to Lock My CAIR Record form at CAIRweb.org/cair-forms. 3. If you change your mind, complete the Request to Unlock My CAIR Record form.
- Fax printed forms to 1-888-436-8320, or email them to CAIRHelpDesk@cdph.ca.gov.
For more information, contact the CAIR Help Desk at 800-578-7889 or CAIRHelpDesk@cdph.ca.gov
ASSIGNMENT OF BENEFITS FORM
All professional services rendered are charged to the patient and are due at the time of service, unless insurance coverage is verified and Integrative Pediatrics and Medicine (IPM) is a participating provider. Necessary forms will be completed to file for insurance carrier payments.
Assignment of Benefits
I hereby assign all medical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including private insurance and any other health/medical plan, to issue payment check(s) directly to IPM for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.
Authorization to Release Information
I hereby authorize IPM to: (1) release any information necessary to insurance carriers regarding myself and/or my dependent’s illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing.
I have requested medical services from IPM on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.
I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges (copay, coinsurance and/or deductible) incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.
Functional/Integrative Medicine Specialty Laboratory Testing Informed Consent
The purpose of Integrative and Functional Medicine laboratory testing in our office is to evaluate nutritional, biochemical, or physiological imbalance and to determine any need for medical referral. These lab tests are not intended to diagnose disease. This office utilizes conventional lab tests as well as functional medicine assessment.
Functional and Integrative Medicine assessment is designed to assist our doctors and other healthcare providers in finding the underlying causes of your family member’s conditions. Functional medicine has evolved through the efforts of scientists and clinicians from the fields of clinical nutrition, molecular biology, biochemistry, physiology, conventional medicine, and a wide array of scientific disciplines. Functional medicine evaluates the body as a whole, with special attention to the relationship of one body system to another and the nutrient imbalances and toxic overload that may adversely affect these relationships. Other medical physicians may or may not agree with the necessity for—or our interpretation of—these tests. If you have any questions or concerns, please discuss them with our doctors.
Integrative Pediatrics and Medicine (IPM) is not responsible for any costs associated with any Functional or Integrative testing. Most of these tests are not covered by insurance companies. It is our policy that all patients should pay the cash price for these tests. Submitting claims to insurance companies can be time consuming and result in non-coverage of tests and significantly higher fees than the cash price paid upfront. We will assist families as able to submit tests to insurance. We make no guarantees that your insurance company will ultimately cover the costs of these tests, even if they say they will when you speak to them. It is your responsibility to understand your plan and benefits and discuss this with your insurance company. IPM is in no way responsible for any fees you may incur from these tests.
I have read and understood the above policy and agree to it for myself and all current and future family members. I understand that if I do not pay the cash price upfront, the cost of the tests may be significantly higher if insurance does not cover the tests and I am solely responsible for all costs.
I acknowledge that all parents and legal guardians with medical rights in your family are aware of these office policies and agree to all the policies as stated in this office policy document. We agree to be patients of Integrative Pediatrics and Medicine Studio City and to be treated by the medical staff at this office.
At Integrative Pediatrics and Medicine (IPM), we provide a number of services that are not covered by insurance. Coordination of care is central to making sure that children get good quality healthcare. This means that multiple hours are spent providing services that insurance does not pay for.
Some of these services include processing various administrative requests, handling refill requests outside of office visits, 24 hour texting service, email, phone and video service during office hours, performing phone consultation with other pediatric specialists, securing medical records from other providers, filling paperwork on your behalf, providing same day or next day visits so you don’t have to go to urgent care, decreasing patient volume in the office compared to a standard medical practice, decreased visit wait times, and numerous other items.
To cover that administration, we charge a small annual administrative and concierge fee per family. (“Family” means any parental unit and their immediate children).
This fee is subject to change in the future, but no changes will be made without notice via email. It is your responsibility to have a working email with the office and ensure you are receiving our periodic emails. Patients will likely be grandfathered in at certain price levels. New patients to the office may pay higher fees while earlier patients may be grandfathered at a lower rate (though the rate may still change yearly).
Fees are expected to be paid before January 1st of each year. Fee announcements will be made in October/November of each year and updated in the terms of service on our website. Families have a chance to pay the fee by any means they wish (cash, credit card, check, etc). If you do not wish to go through the hassle of sending in new credit card information, paying in cash, etc, express pay will be used for the administration/concierge fee at the rates decided. If we do not hear from you, we will assume you would like us to use express pay for this payment. Payment details will be discussed with each family should there be any questions. The administration fee is subject to increase in future years. You may choose to opt out of the annual administrative fee and pay a-la-carte for these requests instead. IPM provides the one-time administrative fee at a significantly discounted one-time rate. This agreement shall remain in effect from 2021 forward, for all future administration fee payments.
If you leave IPM for any reason, you must notify us via email that you will not be returning to close your account (email@example.com). Only an email will qualify as notice of closing your account with IPM. We will automatically close your chart if you have not come to the office for a visit in over 2 years.
I have read and understood the above policy and agree to it for all current and future family members who are patients of IPM. This waiver shall remain in effect for all future years for myself, my family and any future children. I can opt out of this waiver by writing at any time. If the fee becomes burdensome for your family, please speak to our staff and we will discuss what arrangements can be made. Concierge medicine is not for every family. If this is not for you, IPM understands and will help you find a better fit for your family.
Membership Fee Scale
The full yearly fee will be paid at time of your first visit. This will cover you for 1 year. Patients will be charged a prorated fee for year 2 in the end of December/early January. After year three, you will become a member at the family rate.
This rate will be decided on a yearly basis. For 2022/2023 it is set at $625 per family
First year Fee
Dr. Joel Warsh $900
Dr. Tiffany Jumaily $625
Year two Fee – Prorated based on date of joining to be paid in Dec/Jan – Please check your office policies docusign for your rates
Year 3 and beyond – Special family rate
The Family rate for 2023 is $625 for Dr. Tiff and $675 for Dr. Joel
*This amount is subject to increase in the future.
Our office only has capacity for a certain number of patients. Therefore, we reserve space in our office for the year for those that join our office family.
Membership fees are fully refundable for 14 days from the time of payment less admin fees of $150
Following this no refunds will be issued for membership fees. In extreme cases, if any refund should be deemed reasonable and authorized by the office, a prorated share may be returned. Refunds will only be issued after all claims have been paid in full.
There are no refunds for any in office visits, charges or procedures except in the case where a patient pays for an item which is later covered by their insurance. When their insurance pays, a refund for those same services will be made in full. All refunds must be completed by 6 months from the date of service. Should any charges be accidently or incorrectly charged by our billing department to the patient for any reason, the charges be refunded in full regardless of length of time from DOS.
Nutritional and Herbal Supplements, essential oils and other products
According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201(g)(1), the term drug is defined as an “article intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease.” Technically, vitamins, minerals, trace elements, amino acids, herbs, essential oils or homeopathic remedies are not classified as drugs. However, these substances can have significant effects on physiology and must be used rationally. In this office, we provide nutritional counseling and make individualized recommendations regarding use of these substances in order to upgrade our patient’s diet and to supply nutrition to support the physiological and biomechanical processes of the human body. Although these products may also be suggested with a specific therapeutic purpose in mind, their use is chiefly designed to support given aspects of metabolic function. Use of nutritional supplements may be safely recommended for patients already using pharmaceutical medications (drugs), but some potentially harmful interactions may occur. For this reason, it is important to keep all of your healthcare providers fully informed about all medications and nutritional supplements, herbs, or hormones you may be taking.
Sale of Nutritional Supplements at Integrative Pediatrics and Medicine (IPM)
You are under no obligation to purchase nutritional supplements or any other product at our clinic. As a service to you, we make nutritional supplements and other products available in our office. We purchase these products only from manufacturers who have gained our confidence through considerable research and experience. We determine quality by considering: (1) the quality of science behind the product; (2) the quality of the ingredients themselves; (3) the quality of the manufacturing process; and (4) the synergism among product components. The brands of supplements that we carry in our facility are those that meet our high standards and tend to produce predictable results.
While these supplements and products may come at a higher financial cost than those found on the shelves of pharmacies or health food stores, the value must also include assurance of their purity, quality, bioavailability (ability to be properly absorbed and utilized by the body), and effectiveness. The chief reason we make these products available is to ensure quality. You are not guaranteed the same level of quality when you purchase your supplements from the general marketplace. We are not suggesting that such products have no value; however, given the lack of stringent testing requirements for dietary supplements, product quality varies widely.
If you have concerns about this issue, please discuss them with our staff
I have read and understood the above policy and agree to it for all current and future family members who are patients of IPM.