Welcome to Functional Medicine SF Thank you for your interest in working with Functional Medicine SF. The office of Stephanie Daniel D.O., & Lisa Deptula P.A., Please visit our website, functionalmedicinesf.com, for additional information Please do not hesitate to email us with any questions or comments you may have at [email protected]. At this time, Dr. Daniel accept patients, aged 18 and over If you are under 18, please contact our staff at [email protected] Thank you! Please check the boxes below to indicate that you meet these basic requirements. What Provider are you Interested in?*Stephanie Daniel D.OAre you 18 years of age or older?*Yes, I am 18 years of age or older.No, I am not at least 18 years of age.What are your Functional Nutritional Needs and Wants?*Please be as comprehensive as possibleHow many doctors have you been to for this medical concern?0-23-67-10Provide information on all the specialist you have been to:Allergist, Cardiologist, Dermatologist, Endocrinologist, Epidemiologist, Gynecologist, Immunologist, Infectious Disease Specialist, Microbiologist, Neurologist, Oncologist, ENT Specialist, Psychiatrist, Rheumatologist, UrologistSpecialtyNameDate Do you consider your health stable, with no hospitalizations in the past year?*YesNoPlease explain details:*Do you have severe neurological conditions such as seizures, loss of consciousness, fainting or autonomic instability?*YesNoPlease explain details:*Do you have MS (multiple sclerosis), ALS (amyotrophic lateral sclerosis) or Parkinsons? **YesNoPlease explain history of illness*Do you suffer from severe anxiety, depression, rage,Bi-Polar, PTSD, OCD or any other Mental Health Issues?*YesNoPlease explain details*How did you hear about FMSF*Are you male of female*MaleFemaleAge*Please enter a value between 0 and 99.Have you been evaluated and or treated by another medical provider for this medical complaint?*Yes, I have been to other providers for this medical complaint.No, I have not been to other providers for this medical complaint.Current Medical Diagnosis and Complaints*Medical Diagnosis and ComplaintsDate Symptoms Started Are you currently taking any medications?*No, I do not take medicationYes, I take medicationListName Of MedicationDosageDate Started On a scale 1-10 How ready are you to: (10 being I will do anything, 1 being I'm not that motivated)Significantly modify your diet*10987654321Take nutritional supplements*10987654321Keep an updated health journal*10987654321Engage in relaxation techniques*10987654321Modify your lifestyle*10987654321Do regular Laboratory work to evaluate your progress*10987654321Which statement resonates more with you*It’s the doctor's job to heal me.It’s my job to heal myself with the guidance provided by FMSFFunctional Medicine SF Policy Acknowledgement Click here to read the PoliciesScheduling an appointment; Initial appointments are made via the patient portal in MD-HQ (once you have registered) We will email you an invitation to our secure, online medical record system (MD-HQ: Patient Portal) where you will be able to fill out our new patient intake form and other details. You are required to complete your intake forms prior to scheduling. Please upload any prior lab results, supplements and medications you may be taking to your "Patient Portal" in MD-HQ. Established Patient: request an appointment time via the Patient Portal.*Yes I understandOffice Visit Charges; Please be aware that your scheduled appointment time includes time the physician utilizes to review your chart, update chart notes, interpret labs and communicate on your behalf with other practitioners. The New Patient consult includes 90 minutes of face-to-face interaction Dr. Daniel spends time after the appointment reviewing chart paperwork and preparing other forms directly related to your individual care. If you are late for your scheduled appointment you will be seen for the remainder of your scheduled appointment time and billed for the entire appointment. If your appointment extends beyond the scheduled time you will be billed for that time in 15 minute increments depending on the time actually used by the provider in coordinating your care.*Yes I understandPhone/Video Zoom.us Appointments; Functional Medicine SF offers patients the ability to communicate via the videoconferencing platform, Zoom.us, if, the arrangement is agreed to by both parties. Zoom places security as the highest priority in the lifecycle operations of its public and hybrid cloud networks. Zoom strives to continually provide a robust set of security features to meet the requirements of businesses for safe and secure collaboration. Host and Client authenticated meeting: A host is required to authenticate (via https) to the Zoom site with their user credentials (ID and password) to start a meeting. Client authentication process uses a unique per-client, per-session token to confirm the identity of each participant attempting to join a meeting. Each session has a unique set of session parameters that are generated by Zoom. Each authenticated participant must have access to these session parameters in conjunction with the unique session token in order to successfully join the meeting.” For more information about Zoom.us security and privacy, please see: https://zoom.us/docs/doc/Zoom-Security-White-Paper.pdf Insurance companies typically do not provide reimbursement for Zoom.us sessions. Functional Medicine SF will not provide you with documentation or a procedure code to seek reimbursement from insurance companies for Zoom.us sessions. You will be responsible for the cost of Zoom.us sessions. Agreement I have been informed of and understand the risks and procedures involved with using the videoconferencing technology, Zoom.us. I agree to the terms listed above and I hereby voluntarily consent to the use of Zoom.us for sessions with my provider. I agree that Functional Medicine SF should not be held liable in the event that any outside party passes Zoom.us's security and discovers personal or confidential information. *** You must provide your consent to be able to use Virtual Video Appointments *** Phone or video consultations are available for patients who live in or out of the area after scheduling your initial appointment in person. Phone/video appointments will follow the same fee schedule. Virtually all services that can be done in person can be done via phone or video consultation. Lab tests can be ordered that can be performed in your area, and we may also order medication from your local pharmacy or that can be shipped to you.* Yes I understandContinuing Care ; To ensure that each patient understands their commitment and expectations and to increase our quality of care we would like to point out the following: Follow-up consultations must take place per patient recommendations. Continual failure to comply with protocol recommendation timeline will result in dismissal from functional medicine SF.*Yes I understandCancellation Policy; Cancellation of Appointments: Due to the popularity of requests for new patient consultations, there is a 14-day cancellation policy, and your appointment must be confirmed at least 14 days prior to your scheduled consultation. You may cancel your appointment by sending a secure message or cancellation request through the patient portal. If you have not received confirmation that we received your cancellation either by phone, email or patient portal message, it means we didn’t get your cancellation request and you’ll need to submit it again. The late notice fee is the cost of the new patient appointment, half of which will be waived if you complete a rescheduled appointment. Appointments canceled prior to the 14-day window will not incur a cancellation fee. For established patients, cancellation must be 7 days in advance. If cancellation is at least 48 hours prior but less than 1 week, established patients will be assessed a $50 fee. For cancellation within a 48 hour window prior to the scheduled appointment, a fee of 50% of the appointment fee will be assessed for late cancellation the first time and for subsequent late cancellations, the full amount of the appointment will be charged. For established patients, Health Coaching Appointment cancellation must be 24 hours in advance. If cancellation is at less than 24 hours, established patients will be assessed a $50 fee. Cancellations made by regular email are not considered valid.*Yes I understandYou are REQUIRED to have a separate primary care doctor; VERY IMPORTANT Dr. Stephanie Daniel offers functional medicine consultation only. We do not offer after-hours or urgent care - you must have a primary care doctor for this purpose. This also means she is unable to respond to urgent requests of any sort, including messages and phone calls.*Yes I understandPrescription Refill Request; It may take up to 1 week to process a prescription refill. Please plan ahead to avoid any interruption in your medications. Prescription refills must be faxed to our office by your pharmacy. Our fax # is 415-466-8031. We cannot guarantee that refill requests sent another way will be seen and addressed in a timely manner.*Yes I understandMedical Records and Forms Requested; The cost of having Medical Records sent to you or your doctor is $100. You may download any available lab work and patient notes from the portal directly free of charge. Medical records can only be released with your authorization. A medical records release form is available for download on our website or through the patient portal. Please allow 7-10 business after you have signed the release form to receive your records. You are responsible for obtaining previous medical records from other physicians or health care providers. Please contact your physician or other health care provider to obtain these records. Your records should be mailed to the address below or faxed to 415-466-8031. Forms that you need filled out outside of an appointment time will be billed at the standard hourly rate of for the amount of time required of either Dr. Daniel* Yes I understandPayment Options: Payment is due at the time of service. Our office accepts cash, checks, Visa, MasterCard, American Express and Discover. When you schedule an initial visit, we request a credit card on file to hold the appointment for you. No charges will be applied to your credit card unless you miss or cancel an appointment without proper notice. On the day of your scheduled appointment, all charges for consultation, as well as laboratory testing that does not need to be paid directly by you will be itemized and reviewed with you. Payment is due on the day of service. Most laboratory testing is separate and not billed at the time of the appointment. Follow-up or virtual consultations will be billed to your credit card on file in our office unless you provide other payment information and instructions prior to your appointment. If additional lab tests are required and our office sends test kits, the appropriate fees will be charged to your account upon your approval of the estimate that is sent via the portal. We also accept payment from Health Savings Accounts (HSA) or Flexible Spending Accounts (FSA). Functional Medicine SF does not accept insurance or Medicare and we cannot assure you that services (office visits, video/phone consultations or lab tests) will be reimbursed. You will be provided with diagnosis and procedure codes to assist you with possible insurance reimbursement. ** Please note that we are not Medicare providers and are opted out of the Medicare program. Our services cannot be submitted to Medicare for reimbursement. If you have an HSA (Health Savings Account), functional medicine consultations and prescribed supplements are allowable, tax-free expenditures. Health Savings Accounts are a new option for health insurance and they have two parts. The first part is a health insurance policy that covers large hospital bills. The second part of the Health Savings Account is an investment account or retirement account from which you can withdraw money tax-free for medical care. Unused money accumulates with tax-free interest until retirement, when you can withdraw for any purpose and pay normal income taxes. We strongly urge you to look into an HSA as an alternative insurance choice. To find out more, please go to www.hsainsider.com. We recommend that everyone ask their insurance providers what type of out-of-network coverage they offer prior to using our services.*Yes I understandInsurance Expectations: Functional Medicine SF does not accept insurance. We provide a Superbill, which can be submitted to your insurance company for reimbursement if you have an insurance that provides an out-of-network benefit. If you are unsure, call the member services number on the back of your card and inquire about your plan. You can let them know you are planning an appointment with an out-of-network physician and want to know what percentage of your visit will be eligible for reimbursement. Common codes used for appointments include 99205, 99215, 99214 and 99354. For virtual appointments, we use the following code most frequently: 99443 and 99444. Again, HSA and FSA accounts are accepted.*Yes I understandPortal Messaging: Portal Messaging communication with you will be limited to answering questions regarding side effects or clarification of therapy. Any communication that requires clinical decision-making will best be addressed in an office visit or by a scheduled phone consultation. The best determinant is: does your question require a “yes” or “no” answer. If so, email communication is welcomed and your inquiry will be addressed within 48 hours. If not, we will request that you call the office to schedule either a brief phone consultation or to schedule an office visit. Dr. Daniel receives many inquires and won't always be able to respond to your updates or to messages that are not related to your current regimen. When time allows, she will do her best to answer quick questions, but this is not guaranteed. All email correspondence should be done via our secure Patient Portal messaging system once you are an established patient. If you are expecting a response and do not get one within 48 hours, please call the office during phone hours if you need to reach us. (415) 390-2060. If your inquiry seems to require a change in your protocol or you are experiencing new onset of different symptoms, this usually indicates it is time to make a follow-up appointment.*Yes I understandEmail Policy: Email communication is done only through the patient portal and will be limited to answering questions regarding side effects, clarification of therapy or logistical questions. Any communication that requires clinical decision-making will best be addressed in an appointment. The best determinant is: does your question require a “yes” or “no” answer. If so, patient portal communication is welcomed and we will attempt to address your inquiry within 48 business hours or as soon as possible. If not, we will request that you request an appointment via the appointment section of the portal. Dr. Daniel and Dr. Cole receive many messages and won’t always be able to respond to your updates or to messages that are not related to your current regimen. When time allows, they will do her best to answer quick questions, but this is not guaranteed. All patient portal correspondence should be done via our secure messaging system in the patient portal, MD-HQ, once you are an established patient. If your inquiry seems to require a change in your protocol or you are experiencing new onset of different symptoms, this usually indicates it is time to make a follow-up appointment.*Yes I understandOut of State Patients; If you are out of state and have not had an initial in person consult, Dr. Daniel can still work with you on a consultative basis. This means she can take a look at your history, lab reports and current treatments and advise you on how she would approach your case if you were her patient. She can make suggestions for further testing you may need, and offer suggestions for interventions and changes to your regimen that could further support you in finding optimal health. She cannot, however, order labs or prescribe medications unless she has seen you at least once in person in her office. Many out of state patients have been able to achieve the optimal wellness they are seeking by working with Dr. Daniel in conjunction with their own doctors who can follow the recommendations offered to them.*Yes I understandHave you read and understood the policies of FMSF*No, I have not read and or do not understand the policies of FMSFYes, I have read and understand the policies of FMSFFMSF New patient Pricing The New Patient Intake appointment is the first step for all new patients. The intake process is designed to save money and time in the long-run by obtaining a full history and assessment and ordering of necessary diagnostic testing for evaluation before your fully personalized treatment plan is implemented. Identifying the underlying root cause of your symptoms will help us formulate a plan to bring you the results you desire. The New Patient Intake serves several purposes. It enables Dr. Daniel to more accurately estimate how long your treatment program will last, what it will include and an estimation of cost. It gives you the chance to ask any questions you may have about your condition and what you should expect, and it provides an opportunity for us to get to know each other and determine if our clinic will be a good fit for you over the long-term. The New Patient Intake includes: An initial, thorough review of your detailed medical history, as well as a review of relevant lab work if available (* applies to the past 6 months of testing. If there is an extensive history that goes back years, an additional fee to review all of this information will be assessed.) A detailed review of your Life Health Journey and current symptoms A detailed review of your diet and nutritional factors, lifestyle and supplements A 90-minute in-person consultation with Dr. Daniel A 45-minute post appointment consultation with our Functional Medicine Nutritionist and Health Coach with info on our approach to nutrition and some favorite recipes Recommendations and orders for further testing (as necessary) Access to Nutrimentrx.com with Functional Medicine SF discount of 15% $795 at time of service (Bundle both and pay $450 x 3 months) The First Follow-up Appointment: Plan Implementation This is a 60 minute (in-person or virtual) consultation with Dr. Daniel A 45 minute post appointment consultation with our Functional Medicine Nutritionist and Health Coach. A treatment plan including targeted nutritional therapy, personalized supplement plan, prescriptions as necessary and lifestyle therapies. $550 at time of service (Bundle both and pay $450 x 3 months) *Yes, I understand FMSF new patient pricingNo, I do not understandI understand Functional Medicine SF does will not bill or submit to any insurance agency or Medi-care or Medi-Cal*We provide SupperBills for you to provide to your respected medical insurance carrier or system.Yes, I understand I must provide payment at time of service.No, I want to submit the bill to my insurance carrierNo, I want to use Medicare or Med-iCalYou understand FMSF is Virtual Medical Practice.*Medical appointments can take place via Video Conferencing. Yes ,I understand FMSF is a complete Virtual Medical Practice.No, I do not understandYou understand you must attend a webinar to complete your registration*You must attend a webinar to complete your registration. If you can not make any of these times please contact our office to schedule a phone call. Monday at 12:15 PM PDTWednesday at 5:15 PM PDTFriday at 10:00 AM PDTName* First Last Email* Phone****IMPORTANT NOTE: This will take you to a short video that completes the application. Please add the domain “@functionalmedicinesf.com" to your contacts/safe senders list in your email client or the confirmation email will be sent to your spam folder*** This iframe contains the logic required to handle Ajax powered Gravity Forms.