Please read and sign the form below. Once you click submit, you will automatically be presented with the next form. Your computer may be slow at accepting signature and moving you on to the next page. 

 

FINANCIAL AGREEMENT and PRIVACY PRACTICES

  • I authorize treatment for myself or of the person named above. I understand that I’m directly responsible for all the charges incurred for medical service for myself and dependent (if I am not the patient being seen by Green Palms Health and Wellness). Payment will be collected prior to seeing the Green Palms Health and Wellness physician if not paid online prior to your appointment. I authorize treatment for myself or of the person named above and agree to pay all fees and charges for such treatment. Should my payment method fail to cover costs for service.

  • Our No-Show fee will be $50 which is required to be paid before your next appointment. RETURNED CHECKS: You will be charged a $30 fee for each returned check. 
  • Billing: We collect consultation fee upfront prior to seeing physician. We prefer cash as any medical marijuana business prefers. Although, we will accept credit card with additional $5 processing fee or check. If you cannot pay your entire balance at time of visit, please make payment arrangements prior to coming in to see our physician.

    COSTS for our physician visits (Not covered by any health insurance).  Payment online is available (email us to get our access code and directions although to pay online).

    Initial Evaluation – $250 (all physician fees are paid upfront prior to seeing physician to simplify and eliminate need for check out process).

    Depending on patient diagnosis and complexity of health condition(s) physician may require follow up visits every 70 days – $50-75 depending on length of time needed to work on dosages and current medication lists.

    Renewal at 210 days – $199 (we recommend you make your appointment 2-3 weeks prior to not interrupt care).

    Collections:  If a payment arrangement is made and I am unable to pay balances due upon agreement I am aware Green Palms Health and Wellness will turn over my account to a collections agency within 30 days of default.  I agree to pay legal interest, collection expense, and attorneys’ fees incurred to collect any amount if it is not paid within 30 days of service payment failure. 

 

Privacy Practices: 

Treatment: Your health information may be used by staff members to disclose to other health care professionals for the purpose of evaluating your health, making appointments, diagnosing medical conditions and providing treatment. For example if our physician requests lab tests the results may be disclosed to other physicians whom request directly from us. In most cases, we do not request lab tests. There is the rare case this may happen example: High amounts of opioids in combination of Medical Cannabis. This may require additional tests and review of our physician and your primary care physician /specialist to ensure the results and goals noted in your 1st visit are along the lines of agreement of physician and patient.  LAW ENFORCEMENT: Your health record may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with governmental mandated reporting. Your health information may be disclosed to public health (medical marijuana office of use aka Florida Health Department) as required by law. 

  • By typing your full legal name, this serves as your legal signature and that you acknowledge you have read and agree with or will comply with the terms of the document you are signing under penalty of perjury.

 

  • By typing your full legal name, this serves as your legal signature and that you acknowledge you have read and agree with or will comply with the terms of the document you are signing under penalty of perjury.