VITALIS Policies and Procedures, Privacy Policy, and Consent to Treat

THIS PAGE IS FOR REFERENCE ONLY, AND IS EXECUTED WITH THE PATIENTS SIGNATURE PRIOR TO THEIR INITIAL VISIT

I. Acknowledgement of Payment And Cancellation Policy

1. Payment:

By my signature below, I understand, acknowledge, and agree that I am fully responsible for payment of services provided to me by VITALIS METABOLIC HEALTH, PLLC (“Vitalis”) and that co-pays and deductibles or self-pay payment must be made in full by credit or debit card at or before the time of service. I understand that VITALIS does not accept cash or personal checks as forms of payment.

I understand that treatment and services provided by Vitalis may not be covered by my insurance. If this occurs, Vitalis will provide information to me to assist me in my claim for reimbursement to my insurance carrier but will not submit these claims to insurers on my behalf. I further acknowledge and agree that if I choose to submit any bill or itemized receipt to an insurance carrier for reimbursement for these services, that Vitalis is exempt from any dispute regarding reimbursement.

Please remember that you are 100 percent responsible for all charges incurred: your physician’s referral and our verification of your insurance benefits are not a guarantee of payment. We highly recommend you also contact your insurance carrier and check into your coverage for our services. Do not assume that you will not owe anything if you have more than one insurance policy.

Transparent Pricing:

Approximate Medicare & Commercial insurance contracted rates:

New Patient Visit: $200-$275
Established patient Visits: $85-$200

May not be covered by Insurance and may be additional to the above or your copay:

Body Composition Analysis Scan: $7.50
(Scan Frequency: New patient visit, every 4-6 months after that)
Initial Patient Questionnaires: $15-$30
(Frequency: New Patient visit only)

Discounted self-pay (out-of-network or uninsured patients):
(These rates include Initial patient questionnaires and body composition scans)

If you are a new patient: $165 per visit
If you are an established patient that switches to self-pay (loss of insurance/goes to out-of-network): $125 per visit
Active-duty military (if no Authorization is provided to us by patient): $125 per visit

The self-pay rate is only available to patients who have insurance that we are not in network with or who are uninsured. We are contractually obligated to bill insurance for all patients who have coverage with any insurance company we are in network with. We offer further discounts for first responders and medical professionals. These additional discounts only apply to self-pay patients that qualify. Call our office to inquire about these discounts.

All amounts will be billed to insurance at the provider’s professional discretion following industry standard coding rules and regional billing rates. Our billed charges will be higher than the contracted rates above. The contracted rate is a close approximation of the amount you can expect to pay if we are in-network, and your insurance company correctly applies the visit’s charges to your deductible. If you have coinsurance, you can expect to pay the contracted rate times your coinsurance percentage rate for any amount above your deductible once your deductible has been met. If you believe a billing error has occurred, or have billing questions, contact our office for next steps.

We do not dispense medication at our clinic. Medications will be sent to your preferred pharmacy. We send all labs to Diagnostic Laboratory of Oklahoma (DLO) or your preferred lab. PLEASE, call your insurance company prior to getting any labs we have ordered drawn to avoid surprise billing. We are not able to quote medication or lab costs to you. Medications and labs may be covered under insurance we do not accept. Please, verify with your insurance.

2. Cancellation:

To fairly and effectively serve patients who wish to receive treatment, the following cancellation policy has been implemented. By your signature below you acknowledge and agree to the following cancellation policy:

Office visits must be cancelled at least 24 hours in advance. Any cancellations with less than 24 hours advance notice, or not arriving to your appointment before 5 minutes after the scheduled start time, will count as a No Show. You are expected to arrive at least 15 minutes before your appointment time. New Patients will only receive one No Show. Established patients will receive three No Shows. After the third No Show we will terminate our established physician-patient relationship and no longer provide you services. Communications regarding this policy will be made over the phone during the cancellation or via phone or email after a no show occurs. This termination will be sent to you via certified mail to the address we have on file.

II. Consent to Email And Electronic Communication

In most cases we will communicate to you via the patient portal or via phone. It may become useful during the course of treatment to communicate by email, text, or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate with Vitalis and its staff, there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages. Parties that may intercept these messages include, but are not limited to:

People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages;
Your employer, if you use your work email to communicate with us;
Third parties on the Internet such as server administrators and others who monitor Internet traffic.

VITALIS employs an email encryption program that ensures that every email sent on our server is secured. If we send you an email it is encrypted both at rest and in transit. Further, if you reply to this email back to us, that email is also encrypted at rest and in transit. If you forward this email, we cannot guarantee that it will remain encrypted. This applies specifically with email and does not cover any other form of electronic communication.

If you are concerned about methods of communication that are more secure, please talk with Vitalis Metabolic Health staff about ways to keep your communications safe and confidential. If you are willing to communicate electronically, with the understanding that it is unsecured and that your information may be accessed or intercepted by others, please proceed with signing the consent below.

III. Consent for Transmission Of Protected Information

I consent to allow Vitalis and its staff to use unsecured email, text, or other means of unsecured electronic communication to transmit to me protected health information as authorized in the Medical Information (HIPAA) Release Form. The information to be released may include the following:

Information related to the scheduling of meetings or other appointments
Information related to billing and payment
Completed forms, including forms that may contain sensitive, confidential information
Information of a therapeutic or clinical nature, including discussion of personal material relevant to my treatment
My health record, in part or in whole, or summaries of material from my health record

I understand that the information to be released may also include the following: diagnoses and/or treatment for alcohol, drug or substance abuse; psychological or psychiatric conditions; AIDS/AIDS Related Complex (ARC) diagnoses and treatment; HIV test results; cancer diagnoses or sickle cell anemia. I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I also understand that I may terminate this consent by providing written notice at any time, but that this authorization will terminate no later than when my treatment relationship with Vitalis has ended.

IV. Primary Care Disclaimer

At Vitalis, we focus exclusively on improving health through obesity management, diabetes management, and clinical lipidology. Although our physician’s primary specialty is Internal Medicine, we do not offer primary care services. We focus on behavior, nutrition, activity, medication, referring patients to surgery, and disordered eating. As part of our services, we co-manage medical conditions when they are an associated disease or co-morbid complication of excess weight but will not perform preventive screenings or “sick” visits (example: the common cold). We strongly encourage all of our patients to enlist with a primary care physician, as this is an integral aspect of receiving the care you need and deserve. We do our best to work closely with your primary care physician and have an open line of communication with him or her.

V. Privacy Policy

VITALIS Metabolic Health, PLLC
3555 NW 58^th ST, STE 910-W
Oklahoma City, OK 73112
www.vitalismetabolic.com
(405) 653-9161
health@vitalismetabolic.com

Privacy Officer: Bryan A. Luff, Practice Manager

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting the Privacy Officer listed on the last page of this Notice.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

Marketing purposes
Sale of your information
Most sharing of psychotherapy notes

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

We never market or sell your personal information.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Effective Date: 7/1/2025

Privacy Officer: Bryan A. Luff, Practice Manager, health@vitalismetabolic.com, (405) 653-9161

I acknowledge that I have received a copy of the Notice of Privacy Practices from VITALIS Metabolic Health, PLLC. This notice describes how my health information may be used and disclosed, and how I can access my information.

VI. Consent To Treat

I give permission for VITALIS Metabolic Health, PLLC to give me medical treatment.

I allow VITALIS Metabolic Health, PLLC to file for insurance benefits to pay for the care I receive.

I understand that:

VITALIS Metabolic Health, PLLC will have to send my medical record information to my insurance company.
I must pay my share of the costs.
I must pay for the cost of these services if my insurance does not pay or I do not have insurance.
I have the right to refuse any procedure or treatment.
I have the right to discuss all medical treatments with my clinician