About My Practice…
Welcome to Innate Health. I am honored to accompany you on your journey towards better health.
In order to begin, I would like you to be fully informed about the nature of our practice and welcome any questions you may have after you have read this document. Along the way, you will find:
Notices - where we describe our practice and ask for your initials and acknowledgement,
Authorizations- where we ask for your signed permission for specific actions
Consents- where we ask for your signed agreement in embarking on a healthcare plan
Depending on your situation, you may find links to one or more forms.
I appreciate you taking the time in getting to know my practice and your rights within in it. Your autonomy in all processes of your healthcare is of foremost importance to me.
~ Mausumee Hussain, MD, MS,
founder and owner of
Innate Health Integrative and Internal Medicine, LLC
Innate Health Integrative and Internal Medicine, LLC (“Innate Health”)
Notices and Acknowledgments
Dr. Mausumee Hussain, MD, MS (“Dr. Hussain”), who is Board certified in Internal Medicine, practices Integrative Medicine at Innate Health. The National Center for Complementary and Integrative Health (NCCIH) explains Integrative Health care to bring conventional and complementary approaches together in a coordinated way. Dr. Hussain integrates practice of Internal Medicine with her complementary education and training in Functional Medicine, Nutrition, Medical Acupuncture, Ayur-Veda and cupping therapy.
Innate Health Integrative and Internal Medicine LLC
Financial Policies
Dr. Hussain provides direct payment fee-for service consultations and treatments at and through Innate Health. Please make note of the following financial policies:
· Payment is due at the time of service and may be made with cash, credit or debit cards only.
· A $100 deposit is required at the time of first appointment booking only, through the patient portal via debit or credit card.
· The $100 booking deposit is applied towards the total fee for the first appointment, at the conclusion of this visit.
· The booking deposit is forfeited in the case of first appointments that are missed without 24 hours notice.
· Credit and debit card details are maintained in tokenized and point to point encrypted form for your security. This means that we do not store your card details in physical records or on computers in our system. For more information on this, click here.
· We reserve the right to charge your card should payment not be completed at the time of service or if subsequent appointments are missed without 24 hours notice.
· Please contact us if you have questions regarding our financial policy. We want to work with you!
Financial Responsibility:
I understand and agree that Innate Health and Dr. Hussain does not take assignment, which means that payment in full will be required with each visit, in accordance with the financial policy outlined above. I understand and agree that I am responsible for all charges incurred for all treatment rendered, including procedures and laboratory tests, even if my insurance company determines that any services are non-covered or excluded, or, in their opinion, are unreasonable or not medically necessary. I also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for Innate Health and Dr. Hussain to take action to secure payment of an outstanding balance owed. Initial Here
Notice of Services:
I acknowledge receipt of Innate Health’s current Fee Schedule (Table A. Fee schedule), and I agree to pay the applicable fees for services and treatments rendered as set forth therein.
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Insurance Responsibility:
I understand that Innate Health and Dr. Hussaindoes not participate in any insurance plans, including Medicare and Medicaid. Dr. Hussain has opted out of Medicare. This means Medicare beneficiaries must enter into a private contract to participate in care offered by Dr. Hussain at Innate Health. If you are a Medicare beneficiary, please click here to complete this private contract.
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I understand that I can request a paper copy of a superbill showing the cost and nature of services, and it will be my responsibility to submit these paper claims to my insurer. I understand that Innate Health and Dr. Hussain make no representations whatsoever to me or others that any fees paid for services or treatments hereunder are covered by my health insurance or any other applicable third party payment plans.
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I understand and agree that Innate Health and Dr. Hussain has advised me to obtain or keep in full force health insurance policy(ies) or plan(s) covering myself; and that the provision of services contemplated herein is not intended to replace any existing or future health insurance or health plan coverage that I may now or in the future carry.
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Notice as to Possible Non-Coverage of Services:
I understand that because of the non-conventional nature of some of Innate Health and Dr. Hussain's services, insurance reimbursement may not be available when I submit my superbill. My insurance company may not pay for acupuncture services, for example, and in some cases, may not pay for office visits where the focus of the consultation is on wellness, herbal medicine, or other complementary and alternative ("CAM") medical services. Some of the lab tests that are ordered, particularly those that are used in support of wellness consultations or are kits sent to labs using innovative approaches to diagnostics may also not be reimbursed.
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Claim Management:
I understand that it is my responsibility to know my insurance benefits. Innate Health and Dr. Hussain may offer some assistance, but given the uncertainty that pervades insurance decisions, cannot be responsible for any information that turns out to be incorrect. To the extent Innate Health can do so without subjecting Dr. Hussain and the practice to the requirements of Health Insurance Portability and Accountability Act (HIPAA), it will respond to insurance requests for information, but will not be obligated to take action on my behalf against an insurance carrier for collecting or negotiating my insurance claim. I understand I may be charged for responding to requests forinformation.
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Cancellation Policy:
I understand that a cancellation fee will be charged to my account in accordance to the policies and proceduresof Innate Health Integrative and Internal Medicine LLC. This includes forfeiting the $100 booking deposit for my first visit and a charge of $50 for my subsequent visits that I have not cancelled 24 hours before my missed appointment.
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Medical and health Care offered: I can expect Innate Health and Dr. Hussain to explain:
· the nature and character of proposed treatment plans and procedures
· the anticipated benefits or results of the proposed treatment
· recognized serious risks and complications of the treatment.
· alternatives to the proposed treatment (including non-treatment)
I understand that I may be required to document my informed consent for certain treatments after I have had an opportunity to discuss the treatment.
I certify understanding that it is my duty to ask if I require clarification of any of the above.
I further authorize the practice to dispose of at their convenience any specimens or tissue taken from my body during my medical treatment.
Treatment Authorization and Consent: I authorize and consent to medical and health care treatment of ______________ by Innate Health and
(Name of Patient)
Mausumee Hussain, MD, MS ("Dr. Hussain").
Duration/Revocation of Authorizations: I understand that the authorizations and consents may be revoked by me in writing at any time. Such revocation will not affect my financial responsibility to pay for services rendered. *I also certify that I am here to receive health care and for no other purpose.
I understand that any aspect of this form that I do not understand can be explained to me in further detail by my asking Dr. Hussain. I certify that I have read it orhave had it read to me, and that I understand its contents. I also understand that a copy of this form is available upon myrequest.
Date:
Patient/Guardian Patient/Guardian Name Printed
Mausumee. Hussain, MD, MS