Doctor’s
Health Assurance is not a health insurance company we provide preventive medical
care by the use of regular medical lab testing along with recommendations for
basic supplementation and referenced treatment regimes designed to correct
biochemical abnormalities. Doctor’s
Health Assurance requires a 2 or 4 -year membership fee and a monthly payment
plan for those below the national poverty level, so that everyone can have the
very best of medical care at the best price. In order to help eliminate
confusion and misunderstandings, Doctor’s Health Assurance, hereinafter “Doc’s
HA” is willing to accept full payment for the 2 or 4 -year with an additional
20% reduction in fees or credits $1,480 or $3,181 as stated and as set forth
with the limitations below. “Doc’s HA”
does not assume any client liabilities, does not provide any type of emergency
services, or is responsible for the misuse of the information provided. The client is agreeable to these conditions
and agrees to the conditions as set forth herein. This agreement shall be construed in accordance with the laws of
the State of California and the laws of the States in which this agreement is
initiated as well as United States of America’s laws. Wherever “Doc’s HA” may decide to carry on transactions it is
understood that any provisions herein which in any way contravenes the laws of
the State of California or the said jurisdiction shall be deemed not to be a
part of this agreement. This is a 2 or
4 -year contract with 8-month follow-ups for a total of four separate test
evaluations during the two-year period with toxic poison screens (not included)
at 50% discount. Any and all
disagreements and misunderstandings will be arbitrated by “Doc’s HA” picked neutral party.
Consent To Treatment: I have been informed of the
risks, possible alternative treatment, and possible consequences involved in the
treatment by means of natural products.
I have hired “Doc’s HA”
to do an individualized health risk assessment on an eight month bases with a
nutritional comparative biochemical analysis, which includes recommendations
for the relief of the conditions stated on the case history with complaints
listed. I further understand that “Doc’s HA” nor any person-affiliated
party with “Doc’s
HA” has made any
representation that the recommendations will achieve the desired results. We
expect common sense to be used, if something makes you uncomfortable or a
supplement disagrees with your system stop immediately and let us know.
This only applies in the
event we have to deal with our client’s insurance carrier for reimbursements.
I hereby assign to: “Doc’s HA” to the extent of my bill for health
care services, and any and all claims, which may have to be taken against my
insurance carrier: California requires
a licensed MD as a referral for our services, if one’s medical insurance is
billed.
(a)
For
benefits provided under policy of insurance or other health care plan,
including but not limited to the
following described policies: As stated on the History Form under
INSURANCE INFORMATION.
(b)
Against
any other party whose negligence may have caused my injuries or who may be
legally responsible for my injuries, illness or health care costs.
Any Questions and to Verify Payment Received Call: (877-224-4970)
I further hereby assign to
“Dr. Al Aguirre the owner of Doc’s HA” a lien in the amount of my bill for
health care services against the proceeds of any insurance policy, or health
care plan, and against any claim which I may have against any other party whose
negligence may have caused my injuries, or who may be legally responsible for
my injuries, illness or health care costs.
The term “Doc’s HA” will hereby mean and refer to Dr. Al Aguirre the
owner of said company.
I hereby direct payment to be
made directly to “Dr. Al Aguirre the owner of Doc’s HA”. I hereby appoint “Doc’s HA” as my true and
lawful power of attorney irrevocable, and full will power of substitution for
me and in my name, to ask, demand, sue for, collect, endorse, sign, and receive
any such insurance or other benefits or claims against other parties for my
injuries. Although “Doc’s HA” shall be granted such
powers contained herein, “Doc’s HA” is not obligated or compelled to exercise
such powers but may do so at “Doc’s HA” discretion. I agree to cooperate with “Doc’s HA” in collecting any such amounts,
including appearing in court if necessary.
“Doc’s HA” is further empowered to request and receive from any
insurance company or health care plan any and all information and documents
pertaining to my policies including a copy of such policy, and any information
or supporting documentation concerning or touching upon the handling,
calculation, processing or payment of any claim.
I understand this Agreement
and the payment hereunder (as more fully described in the “Doc’s HA” Patient
Agreement set forth below) will be accepted by “Doc’s HA” as payment for bills
submitted by “Doc’s HA”. All insurers
and providers of health care benefits are hereby notified that this agreement
is subject to the financial arrangements with “Doc’s HA” as set forth herein.
In the event that I directly
receive any check, draft or other benefits derived from “Doc’s HA” work, at a
time when there is still a balance due “Doc’s HA”, I agree to sign and deliver
such check, draft or benefits to “Doc’s HA” immediately upon receipt, and the
proceeds thereof shall be applied to my bill.
I hereby warrant the information given by me on this form is true and
correct. However, if the information
I have given is found to be
erroneous, I accept full responsibility for the obligations incurred by this
order form. I understand I’m responsible for payment for services and
treatments not covered by other agencies.
I hereby authorize “Doc’s HA”
to release and to permit the examination or copying of any of my medical
records, X-rays, laboratory reports and the results of all tests of any type or
character to such persons as “Doc’s HA” deems appropriate. I also wave all my rights for my services to
be HIPPA law complaint.
In the event that any
provision of this agreement is determined to be invalid or unenforceable, all
other provisions of this agreement shall remain enforceable. Referred By: _________________________ Trial Membership
Signature:_______________________________________ 21-day trial period reverts
to regular 2-year membership plan, unless written request to stop membership
and forfeit membership fee. List number picked _______of the various Health
Plans as outlined below. Page 1 of 2
I
___________________________ agree to the terms as set forth in this agreement
dated:______________
and
to pay the two (2) year membership fee $280.00 and $220.00 for the first
discounted test report that totals to $500.00 and total monthly fee for
8-months: $85.00 X 8 = $680.00 for the next three medical lab tests reports
with re-checks done at least every 8-months plus $60 lab arrangement and
secretarial fees for each test ordered.
Total fees paid: $___________.
Note:
Cash, check or Credit Card with full 2-year payment receives additional 20%
discount or $1,480.00 benefits as stated ($2,780.00) or 4-yr. $3,181.00
benefits as stated ($5,100.00). All “Health Assurance”
memberships require a signed contract in which the clients agree to pay for
their individualized reports as set forth in contract with “Doctor’s Health
Assurance Plan, LLC”. Trial membership gives the client a 21-day trial period
to make up their mind of what program they want before reverting into our usual
2-year membership, in which the client with written request can back out of the
membership and forfeit the fee.
Rep:
_______________________ Make Check Payable Only To: Dr. Al Aguirre, who will
verify payment.
Various Health Plans:
Note: All “Health Assurance”
memberships require a signed contract in which the clients agree to pay for
their individualized reports as set forth in contract with “Doctor’s Health
Assurance Plan, LLC”. Trial membership gives the client a 21-day trial period
to make up their mind of what program they want before reverting into our usual
2-year membership, in which the client with written request can back out of the
membership and forfeit the fee. All of our services are tax-deductible and we
don’t accept assignment.
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